FINAL
Nutritional Counseling
EVERY VISIT!
arterial blood supply of the labia
external and internal pudendal artery
venous blood supply of the labia
external and internal pudendal vein
Vulva
external genitalia of female
Copper IUD
- effective for up to 10 years - Can be used as emergency contraception up to five days after unprotected sex - Quick return to fertility - prevent fertilization - SE: abdominal discomfort after placement and vaginal bleeding or spotting
GBS Screen
- gram positive organisms, colonizes in the lower GI tract, can spread to GU tract - PTL is not a complication of GBSScreen at 35 to 37 weeks - Technique for collecting culture: swab lower vaginal introits, followed by rectum (through sphincter); sensitivity testing to PCN done - GBS culture predictive for 3-5 weeks - GBS in urine then treat even at early gestation and GBS antibiotics with labor necessary with no additional test at 36 weeks
2nd generation progestins
- solve the unscheduled bleeding and spotting because of the longer half lives and increased potency - norgestrel (in implants and mirena) and levonorgestrel -SE: (androgen SE) acne, facial hair, increase LDL and decreased HDL
What disease are we looking for with genetic carrier screening?
cystic fibrosis, tay-sacks disease, caravan disease, sickle cell trait, thalassemia
During what week of the embryonic period does the heart begin to beat and the circulatory system is beginning to form?
week 5
During what week is the nose, mouth and ears starting to take shape along with the intestines and brain beginning to develop?
week 6
During what week of the embryonic period does the earliest synapses in the spinal cord develop, including fingers and toes present with the arms bending at the elbows
week 7
Sacroiliac joints
weight bearing joints that take weight of upper body and distribute it to lower body; synovial joints with hinge movement which allows sacrum to rotate to enlarge pelvis
Symphysis pubis
where 2 pubic bones join, has avascular fibrocartilage disc; inferior margin of symphysis pubis and descending rami create pubic arch
What does "Midwife" mean?
with woman
Ischial spine
Slight projection behind and above ischial tuberosity. Can be palpated vagianally and in labor the station of the fetal head is estimated in relation to them.
Sacral hollow
Smooth concave anterior surface of sacrum
Goodell Sign
Softening of the cervix; 5 weeks
Posterior cul-de-sac
an extension of the peritoneal cavity between the rectum and back wall of the uterus
Sensitivity
% of affected individuals with the disease who have a positive result on the screening test
Specificity
% of unaffected individuals those without the disease who have negative results on the screening test
Midwifery Model of Care
* Recognizes the woman as an individual in the context of her family and community * Supports and protects the normal physiologic process of labor and birth * Establishes the woman as an active partner in shared decision making regarding her healthcare
coitus inttuptus
- 78% effective - Pull out method - Disadvantages: pre ejaculate luid
Symptothermal Method
- 80% effective - Also must monitor cervical secretions - Monitor daily cervical secretions, asses quantity and quality, take BBT daily and record observations on chart - Avoid unprotected sex on menses, preovulatory dys, all day with fertile type secretion, until 3 days of higher temperature or 4 days past peak (14-17 days)
Billings Ovulation Method/cervical mucous method
- 80% effective - monitor cervical secretions daily, assess quality and quantity and record observations - Avoid sex on menses, pre ovulatory days, all days with fertile secretions, until 4 days past peak day (about 14-17 days each cycle) - Most likely to get pregnant when secretions are abundant, clear, stretchy and slippery
Male Condom
- 82% effective - Most commonly used barrier - Non hormonal, sti prevention -SE: decreased sensation, lack of spontaneity
Two Day Method
- 86% effective - Note presence or absence of cervical mucus; record on chart - avoid sex on all days with secretions and one day following stop of secretions (about 10-14 days with each cycle) - Any Secretion TODAY or YESTERDAY than no sex without protection
Calendar Rhythm Method
- 87% effective - Record length of cycle for 6-12 cycles -Identify the shortest and longest cycle -Take the shortest number of cycle days and minus 18 = beginning of fertile window - Take the longest number of cycle days and minus 11= end of fertile window - Avoid unprotected sex in fertile window
Standard Days Method
- 88% effective -Cycle must be 26-32 days long - Track cycle days beginning with first day of menses (note days 8-19 of cycle) - Avoid days 8-19 on cycle (12 days every cycle avoid sex) Day 1: First day of bleeding Day1-7 can have unprotected intercourse Day 8-19 use barrier method or avoid sex Day 20 till end of cycle can have unprotected sex
Diaphragm
- 88-94% effective - Non hormonal; must use spermicide - Must leave in place for 6 hours post sex and no long then 24 hours - Sti reduction, not as high as condoms - Must reapply spermicide with each act ; multiple sizes - Increase chance of UTI, toxic shock syndrome
Invasive Testing for Genetic Disorders
- Amnio: 16-20 weeks (risk of 1/500 SAB) - CVS: transcervical or transabdominal, 10-12 weeks, risk 1/100 SAB and limb defect at earlier gestation **Rhogam after both procedures
Invasive Testing for Genetic Disorders
- Amnio: 16-20 weeks (risk of 1/500 SAB) - CVS: transcervical or transabdominal, 10-12 weeks, risk 1/100 SAB and limb defect at earlier gestation **Rhogam after both procedures!
Ortho TriCyclen
- COC with third generation progestin (norgestimate - First pill FDA approved to treat cystic acne
Ovcon
- COCs - 50 mcg estradiol pill with 1mg norethindrone - effective in women with previous gestational diabetes
Combined Oral Contraceptives (COCs)
- Contraindicated: clotting or clotting disorder, HTN, heart disease, obesity, lack of movement, smoking - decreases blood loss, decrease Fe deficiency anemia, decrease acne, treat hot flashes, decrease ovarian cyst, decrease endometrial cancer, decrease chance ovarian cancer
Injectable Contraceptions
- Effective for 15 weeks -Suppresses levels of FSH, LH and eliminates LH surge - 1 year to return to fertility - Progesterone- only - Contraindicated in current Breast CA SE: weight gain, menstrual disturbance, depression, bone density decrease
Contraceptive implant
- Effective for 3 years - 68 mg of etonogestrel (progesterone) - Suppresses ovulation and thickens cervical mucus -Possible decrease in acne and reduced risk of ectopic pregnancy -SE: unpredictable, irregular bleeding, amenorrhea; ovarian cysts, weight gain, some decrease bone density
Hormonal IUD
- Effective for five years - Progestin only; 20 mug levonorgestrel/day - Prevents fertilization and thickened cervical mucus - Quick return to fertility - SE: irregular bleeding, infrequent bleeding, amenorrhea, prolonged bleeding (first 3-6 mos), frequent bleeding (first 3-6 mos)
Pelvic Exams
- Indicated from 13-20 with complaint or sexually active for 3 years - >21 yearly exam - Not needed to prescribe contraception
Lactational Amenorrhea Method
- Infant must feed every 4 hours in the day and every 6 hours at night - Infant must be feeding on demand - Infant must be younger then 6 months -- Maternal menses must not have returned - infant must receive all nutrition and no more than 5% from food or formula - High levels of prolactin inhibits secretion of gonadotropin releasing hormone thereby preventing ovulation -98-99.5 % effect 6 months PP - low progesterone and higher estrogen
skenes glands
-->lesser vestibular glands or the periurethral glands, open on either side of the urethra, secrete mucus during sexual stimulation and/or arousal -->discharge with palpation can indicate gonorrhea
Spermicides
- Non Hormonal - Do not douche for 6 hours after sexual intercourse - Kills sperm and inhibits travel to uterus - SE: vaginal irritation - 82% effective
Cervical Cap
- Non hormonal, must leave in place for 8 hours and can stay in for 48 hours - Sti protection reduced from condom use - 3 sizes; use spermicide - SE: toxic shock syndrome
Progesterone Only Pills
- Norgestrel OR norethindrone - ovulation suppressed , cervical mucus thickened, activity of cilia in fallopian tubes reduced and endometrium is altered - must take daily at the same time No off week, active pill daily ("mini pill") - Se: increased risk of diabetes, ovarian cysts (because ovulation is possible on method) - Contraindicated in individuals with ovarian cysts
Cervical Cytology Recommendations
- Pap with every woman >21 years old regardless of sexual history - Age 21-29 every 3 years pap smear - Age 30 and older pap every 5 years with HPV testing if not HPV testing then still every three years - Abnormal cytology/paps require further screening - Cervical cancer screening can be discontinued >65 with 3+ consecutive negatives or 2 consecutive co tests in past 10 years
Basal Body Temperature Method
- Take temp every morning around same time before you get up - most fertile 2-3 days before the temperature spike
Rubella
- avoid pregnancy for 4 weeks after vaccination -avoid exposure if not immune and plan for PP vaccination -Ab titer of 1:10 or higher= immune -positive rubella=immune
Systemic HT
- woman herself must be bother by the sx -used for bothersome vasomotor sx that don't respond to other therapies -use only for sx relief, not for prevention -assess woman's individual life preferences and risk factors - most reliable relief of vasomotor sx
Vaginal Ring
-- 15 mcg ethinyl estradiol + 120mcg etonorgestrel -- suppresses ovulation, endometrial thinning and increased cervical mucus viscosity -- Can be removed for 3 hours without losing effectiveness -- Decreased chance of endometrial and ovary cancer -- Rapid reversibility -- Does not effect bone density -- SE: risk for VTE, toxic shock syndrome, vaginal discomfortm HA, decreased libido, nausea and breast tenderness -2x more risk of VTE then COCs
Contraceptive patch (back up method)
-- 2nd and 3rd week: backup method to be used if patient doe snot change or forgets to put patch on for longer then 2 days --1st week forget to put on patch need emergency contraception or obtain from sex for 7 days
Skene's Gland
-->lesser vestibular glands or the periurethral glands, open on either side of the urethra, secrete mucus during sexual stimulation and/or arousal -->discharge with palpation can indicate gonorrhea
FAS
-10% preg women drink ETOH -FAS: leading cause of mental retardation in western civilization -1.9 in 1000 births in america -ETOH causes more neuro damage to developing baby that any other substance -effects: mental retardation, learning/ emotional/ behavioral problems, heart/ face/ other organ defects
nicotine
-11% of preg women smoke -nicotine binds with hgb and decreases O2 and nutrient supply -Risk of miscarriage, placental abruption, PROM, preterm birth, LBW
Perinatal Outcome issues
-12% babies are born premature -8% are LBW -3% with major birth defects -Societal costs of an intellectual disability over lifetime are > $1 mil -Avoiding adverse pregnancy outcomes alleviates human suffering and reduces burden to health system
Adolescent Pregnancy
-13% in US (mostly black and Hispanic, low income, hx of abuse) -Challenges: outcome of pregnancy, SES/ resources, family/ partner support, educational support, risk of repeat pregnancy -Poverty a greater predictor of poor outcomes than maternal age
Iron supplementation
-27-30mg/day elemental PO iron for every pregnant woman -usually found in PNV or multivit -ferrous sulfate= 325mg tab with 65mg elemental iron -If Fe deficiency anemia present: ~Supplementation 1-3tabs/ day divided and increased dietary consumption ~Vit C enhances absorption ~Avoid antacids, dairy, tea at same time as iron -constipation and GI side effects (start at 1 tab/day and increased gradually) -repeat lab follow up in 4-6wks
obesity
-31% of women of childbearing age -infertility, birth defects (esp NTD), labor dystocia, C/S, forceps -fetal/ neonatal death -maternal complications: HTN, GDM, Preeclampsia, wound infection -LGA, difficulty breastfeeding
interconception care for chronic disease
-80% of women have a medical risk that could adversely affect a future pregnancy -HTN, asthma, DM, cardiac disease, anemia, mental health -hypothyroidism (synthroid dose adjustment for proper neuro development) -autoimmune disorders
Female Condom
-82% effective - Non hormonal, prevent STI contraction
Very AMA
->45y - 0.05-0.2% of all births -low parity, high income -outcomes and counseling (esp with comorbidities) -postmenopausal pregnancy (supplemental hormone therapy to prime uterus before IVF) -psychosocial risk (physical/ emotional stamina to parent)
Drug Categories in Pregnancy
-A: human studies, no problems- Folic acid, levothyroxine -B: No human studies, animals healthy OR humans healthy, animal problems- Some abx (amox), zofran, metformin, some insulins -C: humans no studies, animal problems OR no human/ animal studies- diflucan, ventolin, zoloft, prozac -D: human studies show some problems (risk v. benefit)- paxil, lithium, dilantin, some abx (doxy, cipro, sulfas) -X: humans/ animals problems- accutane, thalidomide
Avoid category X (& often D)
-Abx: tetracyclines(doxy- teeth), sulfas (bactrim- jaundice), floroquinolones (cipro- decreased cartilage) -Nonprescription: salicylates (aspirin, pepto), ibuprofen -Antidepressants/ antipsych: lithium, paxil, others risk/benefit -Antiseizures: dilantin -Retinoids: accutane -warfarin -Vitamin megadoses: Vit A -Herbals: black cohosh, st john's wort
Health Promotion, Disease Prevention, Management
-Adequate appropriate family planning -safe sex -regular brushing and flossing -exercise, diet, sleep, stress -well controlled diseases/ vax
Genetic Screening: Ethnic Groups
-Black, Indian, Middle Eastern: sickle cell trait -European Jewish, French Canadian- Tay Sachs -Mediterranean, SE Asian: Alpha and Beta thalassemia
Caffeine/ Artificial sweeteners
-Caffeine: difficulty concentrating, SAB --> 12oz/day OK -Artificial sweeteners: pregnancy category B
Talking about nutrition in pregnancy
-Determine current habits, practices, and knowledge (quality of foods, access, ethnic/ cultural factors, special diets, influence of family habits) -Determine level of motivation -Diet recalls -Diagrams, specific suggestions
Woman as a Unique Individual
-Focus on normalcy rather than a complication waiting to happen -We meet the other needs of women, those not related to pathology -The woman and her life are a large part of the midwife's attention (expectations and experience of pregnancy, perceptions and beliefs, comforts and discomforts, desires, decisions and actions)
Previous Pregnancy History
-GHTN/ Preeclampsia/ Eclampsia -GDM -Postpartum hemmorhage (1L+ of blood loss) -Placental problems -Infant complications: LBW, LGA (>4000g), SGA -C/S (indication), short interval btwn pregnancies
Labs when indicated
-Hep C -varicella titer -If exposure risk: *Parvo B19 titer (cold with face/ body rash- teachers of small children) *CMV titer: (cold sx- school exposure) *Toxoplasmosis titer: cat feces/ raw meat *lyme titer
Food sources of iron
-Meat (liver, poultry, red meat) -blackstrap molasses Fe fortified hot and cold cereals, breads, and grains -spinach -dark leafy greens -beans -tofu -broccoli -potatoes
Definition of Anemia in Pregnancy
-Nonpregnant norm values: 12-15.8hgb, 35.4-44.4hct -1st & 3rd tri. anemia: hgb <11, hct< 33% -2nd tri. anemia: hgb <10.5, hct<32% -Severe Anemia: hgb <7
Use of good interventions
-Oral nutrition in labor -Non-pharm approaches to pain management -Intermittent auscultation -Rest during 2nd stage (labor down) -Open glottis pushing -Delayed cord clamping -Skin to skin -Out of hospital birth
Healthy People 2020
-Reduce LBW and VLBW -Reduce preterm births -increase proportion of women of childbearing age with intake of at least 400ng of folic acid from fortified foods or supplements -reduce proportion of women of childbearing age who have low RBC folate concentrations -increase proportion of women with live birth who received preconception care services and practiced preconception health behaviors ~Discussed proconception care with provider prior to preg ~Took multivit/ folic acid prior to preg ~Didn't smoke/drink prior to preg ~Healthy wt prior to preg ~Used contraception to plan preg
Risks/ Adverse Outcomes of AMA
-SAB (405 increase age 35-44, 60-65% increase age 45+) -ectopic (1.5% less than 35y, 2.5% age 35-44, 6.9% at 45+) -LBW, IUGR, preterm birth IUFD (1:1000 below 35y, 1:440 if 35+) -Preeclampsia, GHTN, GDM, abruption, previa, PPH, hysterectomy -multiple gestation -congenital anomalies (esp. aneuploidy) -cerebral palsy, other neurodevelopmental disorders (r/t IUGR and PTD) -closely spaced pregnancy -C/S, intrapartum interventions -Risks start at 35 but jump significantly at 40
Other Physical Assessments
-STIs -Irregular bleeding -Fibroids -thyroid -signs of PCOS: hirsutism, ovarian cysts, acne, skin tags, acanthosis nigricans, obesity
Anemia at Initial Visit
-establish type of anemia -Fe deficiency usually microcytic (MCV <80), hypochromic -RBC often normal in preg women with Fe deficiency anemia -Consider other causes: menorrhagia, GI tract, celiac, gastric bypass, folic acid/ B12 deficiency, anemia of chronic disease
Weight Gain Recommendations in Pregnancy
-Underwt(BMI<18.5): gain 28-40lb, ~1lb/wk in 2nd/ 3rd tri. -Norm wt(18.5-24.9): gain 25-35lb, ~1lb/wk in 2nd/3rd tri. -Overwt (25-29.9): gain 15-25lb, ~0.6lb/wk in 2nd/3rd tri -Obese (30+): gain 11-20lb, ~0.5lb/wk in 2nd/3rd tri.
Emergency Contraception
-Use up 120 hours after unprotected sex - Ella (30mg ulipristal pill) and plan B one step (1500 mcg levonorgestrel pill) Next choice (generic plan B) or Cupper IUD - available over the counter if >18 years old -SE: nausea and vomitting
Homeodynamic changes of menopause
-a time of change -consider how society views change -consider how woman views change -menopause= variation in endocrine, somatic, and psychosociocultural
New info with HT
-absolute increased risk for breast cancer with HT is 8/10,000 women per year -absolute increased risk for coronary heart disease with HT is 7/10,000 women per year -only one formulation and delivery method was tested in the study (PO) -women in trial were older on avg than typical symptomatic menopausal women - participants were also asymptomatic
Developmental Milestones (Adolescence)
-ages 10-19 -achieving independence from parents -adopting peer codes and lifestyles -establishing sexual, ego, moral, and vocational identities -Assigning increasing importance to body image and acceptance of one's body image
Providing care for menopausal women
-be beside her and assist with the transition - provide wise health advise -identify signs of health compromise - to not medicate her out of this transition but rather to help her to understand and embrace the new woman who will emerge -help her manage sx that SHE finds unacceptable
CAM for menopausal vasomotor sx
-black cohosh is the only herbal therapy for vasomotor sx with demonstrated efficacy -if no relief in 3 months, move on -exercise can be helpful in reducing frequency of vasomotor sx
Menopause
-cessation of menses >1y -it's a physiologic event that has been transformed into a medical event -transition can vary among women within and among cultures
genetic screening and family history
-congenital deafness or malformations -muscular dystrophy -cystic fibrosis -sickle cell disease
HT contraindications
-continued need for pregnancy prevention, pregnancy -undiagnosed uterine bleeding -current breast CA or other estrogen dependent CA -current or past DVT or PE -recent stroke or MI -liver disease
Supports and protects normal physiologic process
-continuous presence, hands on during labor -time and relationship intensive -women's bodies are designed for birth -expectant management (wait til there is evidence that an intervention is needed)
Counseling on adolescent sexual identity
-create open environment -question of sexual identity/ orientation will resolve over time -conversion therapy is damaging and not useful -safe sex practices
AMA and infertility
-decreased #/ quality of oocytes -more prone to aneuploidy -uterus less receptive -decline in sperm quality -age also affects infertility treatment outcomes
Advanced Paternal Age
-decreased fertility -SAB -adverse neonatal outcomes
AMA
-definition: 35+ -social acceptability limit: 40(women), 45 (men) -avg age of first birth increasing- greatest increase in age 35-39
reproductive life plan
-emotional readiness and interest -financial readiness -maximization of personal health status -age and risk discussion
Emotional changes with menopause
-fears the unknown -may withdraw -may decide to change many components of her life -seems irritable and impatient -reacts strongly -a time of reflection, loss, reemergence (who will she be? What will she value? What will she discard?)
Pregnancy associations with weight gain
-fetal weight (SGA with low weight gain or LGA/ macrosomia with increased gain) -preterm delivery with low wt gain -increased C/S with higher gain -childhood obesity, persistence of maternal obesity
Folic Acid
-folic acid needed preconception -decreases NTD -from 1 month before contraception to 3 months of pregnancy -400mcg daily minimum (all women of childbearing age) -1mg/day with DM, epilepsy -4mg/ day with previous NTD -Avg women= 100mcg from fortified breads/ grains, additional small amounts from nuts, leafy greens
"bioidentical HT"
-formulations that are chemically equivalent to hormones produced by woman's body -available in FDA approved formulations -"bioidentical" doesn't have to mean custom compounded
Perimenopause and sleep
-get little REM sleep and wake up out of lower levels of sleep 60-90 times/ night -If don't get REM sleep, brain doesn't get rested and revived- affects memory and concentration
F/U for Anemia at initial visit
-hgb electrophoresis to r/o thalassemia -ferritin (usually low with Fe deficiency anemia) -serum iron and TIBC not as reliable in pregnancy -peripheral smear: not always done as a first line test
Labs for all women
-hgb/ hct -type and Rh -Syphilis -HIV -Hep B (HbsAg) -Rubella titer -hgb electrophoresis (sickle cell screen)
Good news about AMA
-highly educated -high SES -generally healthy, good health choices -better outcomes for kids, decreased rate of SIDS -increased bresatfeeding
Physiology of Anemia in Pregnancy
-increased plasma volume -dilutional anemia -greatest effect in late 2nd-3rd trimester -increased Fe requirements -depletion of Fe stores regardless, especially if Fe deficient preconceptionally
U.S overuse of interventions
-induction -continuous EFM -Routine amniotomy -epidural -routine episiotomy -cesarean
Associations with preexisting obesity
-infertility -SAB -preexisting DM, or GDM -preexisting HTN, GHTN, Preeclampsia preterm birth -cesarean, macrosomia, stillbirth
Puberty
-instability in HPA --> irregular menses -lots of immature follicles, irregular ovulation, high FSH, estrogen/ progesterone imbalance -manifests as menstrual irregularities, emotional changes, questioning/ irritability, determining who she will be -ovaries ovulating irregularly leads to unopposed estrogen, progesterone deficiency, unpredictability
Emotions associated with perimenopause
-irritability, anger -anxiety, apprehension -feelings of panic, vulnerability -uncontrolled crying -perceived inability to cope with complexity of life -depression -b/c progesterone is mood stabilizer -recommend diet, exercise, yoga, counseling
lead paint
-lead poisoning is #1 environmental health risk in industrialized countries -1/6 children- toxic lead levels -powerful neurotoxin -found in homes built before 1978 -peeling paint and paint dust (indoors and outdoors) -water pipes
CNM/ WHNP goals in caring for menopausal women
-listen to all her sx and concerns -be well versed enough to discuss risks/ benefits of various therapies based on patient preference -be aware of multiple routes of delivery (vaginal, PO, transdermal) -understand sx and societal influences that cause women to seek care -be able to articulate issues surrounding "bioidenticals" and use of FDA approved "bioidenticals"
HT regimens
-localized (for vaginal sx only- vag dryness, etc): cream, tablet, ring -systemic- PO, ring (different formulation than localized ring) -Daily or cyclical -if sx are limited to vaginal dryness or irritation, localized vaginal therapy is indicated
Illicit Drugs
-maternal issues: poor nutrition, STIs -Infant issues: LBW, preterm birth, abruption, newborn dependence
Issues in the care of menopausal women
-menopausal women each have unique experiences -women's needs go unmet/ don't feel heard, may to elsewhere or nowhere -get conflicting info from providers v. celebrities/ books/ internet/ friends
Role of hormone testing
-menopause can usually be diagnosed based on sx and menstrual hx -no indication for salivary testing ot individually compunded therapies -goal is sx relief- right dose provides sx relief for individual woman
Menopause v punerty
-menopause is same state of HPO instability -infrequent ovulation, irregular menses, unopposed estrogen, decreased progesterone -manifests as menstrual irregularities, sleep disturbances, mood changes, lack of steady state
Recommendations for hormone therapy
-no longer referred to as hormone replacement because this suggests menopause is a deficiency state and because HT levels are minimal compared to pre-menopausal levels -used to be prescribed to all menopausal women (sx or not) and was viewed as prophylaxis against heart disease and osteoporosis -study showed increased risks of breast cancer and CV disease -many women and clinicians became fearful of HT
Effects of estrogen deprivation on the CNS
-numbness, touch impairment, touch aversion -confusion, memory loss -agoraphobia, anxiety, apprehension -depression, irritability, mood swings -difficulty concentrating, feeling vulnerable/ weepy -feelings of panic
Dental Exam
-poor dental health= PTL/ LBW -annual, poor dentition, severe gingivitis, need for x-ray
Preconception care prevention
-prevention of 50-70% NTD with folic acid -Reduce birth defects (cardiac, NTD, sacral agenesis) d/t poor glycemic control from 10% to 2-3% -Reduce birth defects from exposure to teratogens
HT follow up
-recommended to begin as close to cessation of menses as possible -lowest dose that offers symptom relief -for shortest time possible (ideally no longer than 5yrs but can continue based on individual risk factors and needs)
Adolescent Characteristics
-risk taking behaviors: feeling of invulnerability and belief in supremacy of own power and knowledge (ability to fully understand consequences isn't complete until age 17) -Concern with appearance -desire to conform to group norms -desire to be independent from parental authority
Menopause developmental task
-same as teenager -determine who she will be when she emerges from this time of transition -examine her life now and what does she want it to look like after the change
Consequences of longer living
-several more decades of estrogen deficiency --> * effects in heart, vagina, brain, bone, blood vessels, skin, joints, mucous membranes, and genitalia * changes worsen with time and can contribute to increased risk of coronary heart disease, Alzheimer's disease, etc
adolescent sexuality
-sexual behavior is exploratory/ experimental -attention to adverse consequences not fully developed -Non-coital behaviors: masturbation of/ by partner, fellatio, cunnilingus, anal intercourse
Recommendations for health screening in menopause
-sexual health, vaginal health, bleeding changes -mammogram -bone density testing (usually after age 65) -screening for colorectal cancer -vaccines -sleep, mood, urinary concerns (more r/t aging than menopause)
Psych changes for menopause
-she is accustomed to being very responsible and predictable -fear -feels she doesn't know herself or her body -everyone expects consistency of her (herself, family, society)
effects of high levels of stress
-short term: fatigue, anxiety, poor appetite/ overeating, HA, backaches -long term: decreased resistance to infections, increased BP, heart disease -Pregnancy: preterm labor, LBW *increased CRH (produced by brain and placenta) prompts release of prostaglandins, trigger ctx *stressor earlier in preg= earlier delivery *some stress related hormones(norepi) may constrict blood flow to placenta--> less O2 and nutrients
Physiologic sexual changes in perimenopause
-slower arousal, slower lubrication -decreased blood flow to vagina, diminished clitoral stimulation and labial engorgement, less sensitivity to stimulation -change in neurologic connections, relative numbness -change in orgasmic intensity and frequency -slower ascent to excitement -less intense uterine contractions with orgasm -shorter orgasmic phase
Hot flash triggers
-spicy foods -acidic foods -aged cheeses -hot drinks -caffeine, alcohol, tobacco, marijuana -white sugar -stress -hot weather, hot tubs/ saunas -intense exercise, sex -anger, especially if not expressed
Other physiologic changes of menopause
-stress leads to increased cortisol levels (produced by adrenals- adrenals need progesterone to function) --> increased stress leads to increased severity of menopausal sx - hot flashes can increase body temp up to 6 degrees, increase HR/ BP/ etc
HT risks
-thromboembolism -ischemic stroke -breast CA (combined estrogen/ progestin therapy) (estrogen only arm of study didn't find increase in breast CA) - be attentive to woman's individual risk factors for these conditions: age, cigarette smoking, lifestyle (exercise), BP, DM, elevated cholesterol, obesity, diet, family history
Menopause change
-total lack of steady state physically and emotionally -like menarche change
AMA and long term risks
-trisomy in grandchildren -neuro disorders -DM -male infertility, shorter life span in daughters(esp when AMA >40), childhood/ adult cancers -risks of CA for AMA woman r/t delayed 1st childbearing (breast, uterine, cervical, ovarian, colon, brain, thyroid, pancreatic, bladder)
First prenatal visit
-usually 6-8wks -brain, spinal cord, heart already primarily formed
Engagement
0 station; when presenting part (hopefully head) descends into the pelvis
two-vessel cord anomalies
0.5%-1% of neonates - associated with GI, GU, and CV abnormalities
Domestic violence
1 in 6 pregnant women have been abused by a partner
Muscles of the perineum
1. Ana sphincter 2. Ischiocavernosus 3. Bulbocavernosus 4. Superficial transverse perineal 5. Colles fascia
Pelvimetry questions
1. Inlet: Sacral promontory: Is it reachable? Diagonal conjugate >12.5cm 2. Midpelvis: Sidewalls: Are they straight or divergent? Ischial spines: Are they blunt or sharp? Sacrum: Is it hollow? Sciatic foramen (2 fingerbreadths): Is it wide enough? Interspinous diameter >10cm 3. Outlet: Pubic arch: Is it wide? 2-3 fingerbreadths Tuberosities: Are they widely spaced? >10cm
What are the seven steps of midwifery management?
1. Investigation 2. Identifying the problem or diagnosis 3. Anticipating potential problems 4. Evaluating the need for intervention 5. Development of a plan of care 6. Assuming responsibility for implementation of plan of care 7.Evaluation of the effectiveness of care given and plan
Outlet
1. It is the lowest part of pelvis. 2. Think of it as two imaginary triangles. 3. The top triangle extends from tuberosities to symphysis; the bottom triangle extends from coccyx to the tuberosities. 4. About the same dimensions as inlet but greatest dimension is anterioposterior. 5. Anteriorposterior length from lower margin symphysis to tip of sacrum (hard to measure in real life) is normally >11.5 cm. 6. Space between tuberosities is >10 cm. Angle of symphysis should be wide, >2 fingerbreadths.
Muscles of the pelvic floor
1. Levator ani 2. Pubococcygeus proper 3. Pubococcygeus 4. Pubovaginalis 5. Puborectalis 6. Iliococcygeus
What are the 3 main barriers for LGBTQ care?
1. Limited access to care 2. Experiences shape expectations 3. LGBT invisibility in health care
Inlet
1. Most fetuses enter the inlet in the last month of pregnancy. 2. The inlet needs adequate measurements in three directions: anterior-posterior, transverse, and oblique. 3. In almost all female pelves, the transverse diameter is the longest, so a fetus enters the pelvis in the transverse.
Describe the changes in fetal circulation after birth
1. The gas exchange takes place in the baby's lungs. 2. By cutting the umbilical cord, the placental circulation system is switched off. 3. The fetal heart shunts become closed. Foramen ovale and ductus arteriosis close almost immediately d/t pressure.
Mid pelvis
1. The midplane of the pelvis is the plane of least dimensions. 2. It's called that because it is the part of the pelvis where the fetal head gets held up in active labor. 3. Ischial spines pass through mid pelvis 4. Spines should be blunt and not sharp to allow fetal head to pass. 5. Interspinous diameter is measurable: should be 10cm to allow most fetuses to pass.
Rectovaginal Exam
1. Woman has a retroverted uterus 2. After perineal repair to determine there is no tears in septum 3. Suggested for women over the age of 40
What would informed consent for gentic testing entail
1. competence to understand and decide 2. disclosure of risks and benefits 3. understanding of information and plans 4. voluntariness in choosing testing or no testing 5. consent or authorizing the choice
Ovulation occurs ___ to ___ hours after ___ peaks
10 to 12 hours; LH
How many CFUs to confirm a UTI that needs treatment?
100,000CFUs
Inter spinous diameter is measurable in the pelvis and should be _________ to allow most fetus to pass
10cm
After ovulation, fertilization takes place in approximately how many hours?
12-24 hours after ovulation
What is the recommended age for an initial reproductive health visit?
13-15 years old
Quickening is felt at ....
16-20 weeks
When is pregnancy do you check a CBC?
1st and 3rd trimester
Define/describe discomfort of pregnancy: Headaches
1st trimester - hormonal changes 2nd trimester - increased blood volume, tension, posture 3rd trimester - tension, posture Non-pharm: Cool compress to back of neck, warm or cool compress to forehead; eat, drink, rest Pharm: tylenol 650 mg q 6 hours; stronger headaches without a migraine hx require investigation
When does down syndrome screening take place
1st trimester screen @ 9-13 wks 2nd trimester screen @ 15-20 wks Depending on results, CVS or anmiocentesis
Normal Hematocrits/Hemoglobin in pregnancy
1st trimester: 11/33 2nd trimester: 10.5/32.0 3rd trimester: 11/33
Describe the structure and function of the umilical cord
2 - arteries, 1 vein covered in wharton's jelly for protection The cord epithelium is formed by amnion. No other blood vessels are found in the cord. The cord arises from fusion of the connecting stalk with the yolk sac stalk and allantois at the end of the fourth week of gestation.
bulbocavernosus
2 - ctx reduces size of vaginal orifice
superficial transverse perineal
2 - fix location of central tendinous point of perineum
ischiocavernosus
2 - one on either lateral boundary of perineum; maintain clitoral erection
The angle of the symphysis should be about _______ wide
2 fingerbreadths
Hormone(s) that the Anterior Pituitary Releases
FSH and LH and TSH, ACTH, growth hormone and prolactin
When do you start measuring fundal heights?
20 weeks
Typical estrogen dosage
20-25 micrograms
Normal blood loss with Menstrual Cycle
20-60 ml
Normal Menstrual Cycle Length
21-25 days with 2-6 days of flow
Normal Menstrual Cycle Length
21-30 days with 2-6 days of flow
1 hour glucose challenge test
24 to 28 weeks unless high risk 50g glucose load, serum glucose checked at 1 hour without regard for previous meal, no fasting necessary Follow up if > or = to 130/140 If >200 = GDM
What is the time frame of the embryonic period?
4-8 weeks of gestation
Menopause incidence
40 million in next decade will complete menopause -75% can manage -25% need help (educate, evaluate, guide)
Lead Testing of Mothers
5-9 monitor and repeat testing in one month 15-44 repeat testing in 2 weeks and nutrition counseling (Ca, Fe, Vit C); DOH conduct home visit >44 repeat testing within 24 hours; consider hospitalization and chelation therapy especially 2nd and 3rd trimester
Define/describe discomfort of pregnancy: Insomnia
50% of women experience poor sleep in 3rd trimester - nocturia, back pain, heartburn and hip pain Etiology: hormonal changes, physical discomforts, psychosocial changes, anxiety, emotional distress, estrogen, progesterone, cortisol, prolactin influence sleep cycles; warm baths or showers, warm non-caffeinated beverage before bed, consistent sleep wake cycle, reduce bedtime stimulation, avoid caffeine and simple sugars, exercise but not close to bedtime, meditation, hypnosis, dark room, cool bedroom, avoid ETOH and smoking, avoid fluid bolus before bed
What is the traditional sequence of prenatal visits?
6-28 weeks Q1month; 28-36 weeks q2weeks; 36-40 week Q1week, >40 weeks Q2time per week
Transition from the embryonic period to the fetal period is said to begin ____ weeks after fertilization or ____ weeks after onset of last menses?
8 weeks; 10 weeks
When can you first hear fetal heart tones with a doppler?
9-12 weeks
Identify the composition of amniotic fluid throughout pregnancy
98% to 99% water, with the remainder consisting of electrolytes, creatinine, urea, bile pigments, renin, glucose, hormones, fetal cells (including stem cells), lanugo, and vernix caseosa
What are the current recommendations for cervical cancer screening - pap testing
<21 - no screening 21-29 years - every 3 years conventional cytology without HPV co-test 30-65 years - every 3 years conventional cytology; every 5 years with HPV co-testing >65 years - no further screening if prior screening was negative and no other high risk for cervical cancer >65 years with hx of CIN (cervical intraepithelial neoplasia) grade 2 or 3 or AIS - continue screening for 20 yrs after regression or mgmt After hysterectomy with removal of cervix - No screening unless positive hx of high grade precancerous lesion or cervical cancer HPV vaccinated - regular age specific screening 3 normal screenings after abnormal then go back to regular screening guidelines
The anterior posterior length of the pelvis is normally
>11.5cm
Osteoporosis Screening
>65 years old or start at 60 for women at high risk
Iliopectineal line
A bony ridge on the inner surface of the ilium and pubic bones that divides the true and false pelves
Colposcopy - what is it, when would you perform it
A colposcopy is usually carried out when the results of a cervical screening test indicate there are abnormal changes in the cells of the cervix; If an area of abnormal tissue is found during colposcopy, following use of acetic acid, a cervical biopsy or a biopsy from inside the opening of the cervix is usually done
Describe the development of the placenta
A unique function of the placenta as an interface link between maternal and fetal tissues is to fulfill critical roles such as preventing allograft rejection of the fetus, ensuring fetal nutrient supply along with respiratory gas exchange and enabling the transfer of fetal toxic metabolic waste into the maternal blood circulation for elimination. The placenta also functions as an endocrine organ producing steroid and protein hormones for the protection of pregnancy.
True Pelvis
Bony passageway through which the fetus must maneuver to be born vaginally; shallow anterior wall that is approximately 5 cm long and deep concave posterior wall that is 10 cm long
Labs at 24-28 weeks
CBC, GCT, GTT, repeat T&S depending on RH status (if neg), possibly RBR/VDRL
What performances techniques can affect the quality and interpretation of cervical cytology
Always be gentle Get enough cells Sample every cell type - rub slide or swish in sample to get all cells off <8,000 cells is unsatisfactory sample and no results will be given Avoid obscuring - blood/inflammation/infection, can't see through sample on slide or there are changes in cells from inflammation and give an abnormal result
1st prenatal labs
CBC, RPR/VDRL, blood the, RH with antibody screen, rubella, hepBsAg, GC/CT, u/a, urine c&s, HIV
Knots, loops, torsion, or strictures
Associated with fetal morbidity/mortality
Positive signs of Pregnancy Include
Audibility of fetal heart tones; visualization of the fetus on the ultrasound or by x-ray; fetal movements palpated, fetal movements visible
3 hour glucose tolerance test
Fasting value, 100g glucose mixture drinks, blood draw at 1 hour, 2 hours and 3 hours ACOG and National Diabetes Data Group Normals: 105, 190, 165, 145 1 abnormal: nutritional counseling 2 abnormals: GDM Fasting >126 = GDM
Marginal (Battledore) insertion of cord
Cord is inserted at or within 1.5 cm of the margin of the placenta. May be an insignificant finding but is associated with preterm labor, abnormal FHR patterns in labor (compression), and bleeding in labor (vessel rupture)
Describe common changes of the eye during pregnancy
Corneal edema (due to fluid retention) Decreased corneal sensitivity (due to fluid retention) Decreased intraocular pressure (due to increased aqueous outflow and the effects of progesterone, relaxin, and hCG) Transient loss in accommodation Pregnancy is not a good time for a woman to be measured for new contact lenses or eyeglasses - the changes in the eyes will resolve after birth
What are contraindications of sexual intercourse in pregnancy
Absolute contraindications - Unexplained vaginal bleeding - Placenta previa - Premature cervical dilations - Premature rupture of membranes Relative contraindications - History of preterm birth - Multiple gestation
Once the sperm reaches the zona pallucida, what reaction takes place and what does this reaction do?
Acrosome reaction, small opening of the head releases the contents so binding to the zona pallucida can occur
Naegele's Rule
Add 7 days to the date of LMP (first day of LMP) then subtract 3 months from that date
Mammogram Screening
Age 19-39 annual mammogram when high risk group (1st degree relatives with breast cancer, positive for BRCA1 and BRACA2) Age 40+ mammogram every 1-2 years Age 50+ mammogram yearly
Digital Breast Exam Screening
Age 20-39, every 1-3 years Age 40+, annually
Mammogram
Ages 19-39: for high risk group yearly Age 40-49 every 1-2 years Age 50+ yearly
Discuss impacts on sexuality during: Mid-life
Ages 40-60 yrs old Many report that their libido has changes and sex is not the driving force it once was; Menopause causes changes in sexual desire, expression, and functioning. May have decreased desire due to decreased vaginal lubrication, dryness, dyspareunia, painful spasms of muscles, loss of sensations, fewer orgasms or depth of orgasm.
What is PUBS
Also known as Percutaneous Umblical cord Blood Sampling (or cordocentisis). Less commonly performed diagnostic test to evaluate hydrops, obtain a specimen of fetal blood. Under ultrasound guidance, a needle is inserted in the umbilical cord and a small amount of fetal blood is withdrawn. Risks? Fetal bleeding, umbilical cord hematoma, maternal-fetal hemorrhage, fetal bradycardia
Identify anatomical changes in the respiratory system, including changes in ventilation and lung volume
An increase in thoracic diameter and cephalad rise in the diaphragm change the pregnant woman's lung capacity. Tidal volume increases by 30-40% and vital capacity increases slightly. This hyperventilation probably occurs secondary to the effects of progesterone. It places the woman in a state of respiratory alkalosis, which has the effect of improving carbon dioxide transfer from the fetus to the maternal circulation. It is common for pregnant women to experience dyspnea even when at rest.
Linea terminalis
An oblique ridge on the inner surface of the ilium and continued on the pubis, which forms the lower boundary of the iliac fossa; it separates the true from the false pelvis.
What is autosomal dominant inheritance?
Autosomal dominance is a pattern of inheritance characteristic of some genetic diseases. "Autosomal" means that the gene in question is located on one of the numbered, or non-sex, chromosomes. "Dominant" means that a single copy of the disease-associated mutation is enough to cause the disease
Sacral promontory
Anterior superior edge of the first sacral vertebra. It protrudes slightly into the cavity of the pelvis, reducing the anterior posterior diameter of the inlet.
sacral promontory
Anterior superior edge of the first sacral vertebra. It protrudes slightly into the cavity of the pelvis, reducing the anterior posterior diameter of the inlet.
What are common antibiotic teratogens? and what happens
Antibiotics, Tetracycline: Abnormalities of teeth discoloration. Sulfonamides: Hyperbilirubinemia in neonate. Aminoglycosides: Neonatal ototoxicity.
What are autosomal recessive disorders
Autosomal recessive is one of several ways that a trait, disorder, or disease can be passed down through families. An autosomal recessive disorder means two copies of an abnormal gene must be present in order for the disease or trait to develop
Define/describe discomfort of pregnancy: Fatigue
As many as 95% of pregnant women experience fatigue at some point in pregnancy, making it among the most common pregnancy discomforts. It is often in evidence during the first trimester and then again in the third trimester
Ethnic population screening (population, timing, meaning and appropriate follow-up) for Tay Sachs
Ashkenazi Jewish (1/30 carrier) French Canadian ( 1/15-1/30 carrier) Louisiana Cajun ( 1/27 Carrier). Brain and nervous system disease. Progressive muscle weakness, mental deterioration, blindness. Death by 3-5 years of age. No treatment or cure.
Ethnic population screening (population, timing, meaning and appropriate follow-up) for Familial Dysautonomia
Ashkenazi Jewish; ideally, screening to identify those who are carriers of genetic disorders should take place before conception to ensure couples are fully informed of their reproductive options, or as early as possible in pregnancy to allow couples the opportunity to have prenatal diagnostic testing; DNA analysis for selected alleles; frequency is 1/35, with a detection rate of 99.5%. Screening should be offered to all Jewish couples; if only 1 is Ashkenazi Jewish, screen that person first
Ethnic population screening (population, timing, meaning and appropriate follow-up) for Fanconi anemia group C
Ashkenazi Jews and Afrikaners. Amniocentesis at 15-18 weeks. CVS at 10-12 weeks. Fanconi anemia (FA) is a rare, inherited blood disorder that prevents the bone marrow from producing enough new blood cells for the body to function properly, or that causes the bone marrow to make faulty blood cells. FA increases the risk of some cancers or other disorders; about 10 percent of people with FA develop leukemia.
Retropubic angle
Behind the symphysis pubis. Measures the forepelvis.
What is the current classification system for interpretation of cervical cytology
Bethesda Classification System · cytologic testing - examination of individual cells and the results serve as a screening tool that addresses absence or presence of precancerous or cancerous cells Specimen adequacy: General categorization Interpretation / Results
Define/describe discomfort of pregnancy: Backache
Back pain in pregnancy develops under the influence of progesterone and relaxin that soften the ligaments and joints, as well as the shift in a woman's center of gravity as pregnancy progresses. Incidence: 50-70%. Lower Back Pain: d/t lordosis required for counterbalance; Pelvic floor and pelvic tilt exercises can help strengthen core; Swimming or aquatic therapy relieves joint and muscle pressure by providing a weightless environment that reduces pain in some
Hematologic changes in iron requirements with pregnancy
Because of the increased RBC production and growing fetus and placenta, increased iron intake and absorption is required. It is estimated that the pregnant woman needs 500mg of extra iron during pregnancy, 300mg is used by the fetus and 200mg for normal daily use and loss. To meet this need, increased absorption of dietary iron from the intestines occurs; progesterone mediates a slowed peristalsis in the small intestine and colon, which enhances iron absorption
Describe the effect of pregnancy on the abdominal wall and the skin
Beginning after midpregnancy, reddish, slightly depressed streaks commonly develop in the abdominal skin - - - Striae gravidarum or stretch marks Sometimes, the muscles of the abdominal wall do not withstand the tension to which they are subjected As a result, rectus muscles separate in the midline, creating diastasis recti of varying extent Midline of the anterior abdominal wall skin - takes on dark brown-black pigmentation to form the linea nigra Irregular brownish patches of varying size appear on the face and neck - - cholasma or melasma gravidarum the "mask of pregnancy" Pigmentation of the areolae and genital skin may also be accentuated
Define/describe discomfort of pregnancy: Braxton Hicks Contractions
Braxton Hicks like contractions do not occur in a regular pattern, nor do they cause the progressive cervical dilation and effacement seen during active labor. However they are not "false" because premonitory uterine contractions probably reflect the changes within the uterine musculature that occur with advancing gestation and preparation for labor. The hormonal milieu that stimulates cervical ripening, combined with anatomic pressure of the presenting part on the cervix and the traction generated by uterine contractions also cause the premonitory sign of the passing of the cervical mucus plug
What is the significance of a discolored placenta
Brown - hemosiderin (poor iron circulation) Green - meconium Yellow - chorioamnionitis
Explain the effect of pregnancy on the basal metabolic rate
By the 3rd trimester, maternal basal metabolic rate is increased by 10-20% compared with that of the non-pregnant state 1st trimester - 85 kcal/day 2nd trimester - 285 kcal/day 3rd trimester - 475 kcal/day
The Corpus Luteum
Functions for 8 days after ovulation; secreting increased progesterone, some estrogen and causes negative feedback to hypothalamus and pituitary to avoid more ovulations during the cycle. With no fertilized ovum the luteal cells degenerate and increased LH and FSH occurs which causes menstruation
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Lymphogranuloma Venereum
C. trachomatis(can be genital or rectal mucosa - mostly infections of lymphatics and lymph nodes) Sx: unilateral, painful inguinal lymphadenopathy; pelvic pain; constipation; anal pain; tenesmus; bloody/ mucoid anal discharge PE: fluctuant lymph nodes that may rupture on compression, inflammation of rectal mucosa Dx: clinical s/s, NAAT to r/o C. trachomatis vaginally or of lymph node/ lesion exudate Tx: Doxycycline 100mg PO BID x21d Pregnancy: Erythromycin base 500mg PO 4x/day x21d Treat all sexual partners of last 60 days Sequelae: fistulas, permanent tissue damage
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: HSV
CDC recommends typing via blood testing to guide teaching and treatment decisions. Dx: small, very painful vesicles or open lesions on the mouth, vulva, perineum, or anus. The lesions usually appear in small groups and are disproportionately painful in comparison to their size and depth. They may be fluid filled vesicles. Treatment for initial outbreak are typically treated with Acyclovir 400mg PO TID for 7-10 days. Recurrent outbreaks: Acyclovir 400mg tid for 5 days; partner treatment is not needed. Prenatal: all woman should be asked if they have a hx of herpes or genital lesions as part of their IOB visit; Intrapartum: the greatest risk of herpes in pregnancy is intrapartum transmission to the infant during the woman's initial outbreak. Vaginal birth during primary outbreak can have vertical transmission rates as high as 60%. Vaginal birth during recurrent infections has a lower transmission rate 3% due to the passage of IgG across the placenta. Breastfeeding poses no risk to the infant of women with HSV. Breastfeeding should still be encouraged in all women with HSV unless there is a lesion on the nipple.
Chorionic villus sampling
CVS is an alternative to genetic amniocentesis. CVS is generally performed 10 to 13 weeks after the last menstrual period; transabdominal approaches are preferred because of a lower miscarriage rate; tissue can be analyzed for chromosome anomalies or with enzyme assay, or DNA analysis. Advantages of CVS include early diagnosis before the pregnancy is obvious to others and, for some assays, a decreased waiting period for results. Disadvantages include a risk of SAB, infection, bleeding, and amniotic fluid leakage; uncertainty about long term effects on the infant
Positive PPD Follow up
CXR asap, even in first trimmest, with shielding, CXR deferred after 20 weeks Treat active TB in pregnancy in all cases
What process does sperm undergo in it's journey through the cervix and uterus to prepare to implantation into the ovum?
Capacitation - - removal of the glycoprotein coat from the head of the sperm
Symphysis Pubis
Cartilaginous join with no capsule or membrane with little movement at junction of two pubic bones.
The _____ nerve inner ages the clitoris
Cavernosal
Cervicography - what is it, when would you perform it
Cervicography is a diagnostic medical procedure in which a non-physician takes pictures of the cervix and submits them to a physician for interpretation; Cervicography is no more sensitive than Pap smear screening, and has a higher false positive rate (thus increasing the number of colposcopies needed).
What is the significance of a light placenta
Chronic uteroplacental insufficiency Chromosomal anomalies Maternal tobacco use Congenital infection
CDC guidelines for partner management and tx
Clinicians can provide partner services by counseling infected persons and providing them with written information and medication to give to their partners (if recommended and allowable by state law), directly evaluating and treating sex partners, and cooperating with state and local health departments Expedited Partner Therapy (EPT), also termed patient- delivered partner therapy (PDPT), is the clinical practice of treating the sex partners of persons who receive chlamydia or gonorrhea diagnoses by providing medications or prescriptions to the patient.
What are the available methods of collecting specimens for cervical cancer screening
Collection samples via a spatula, cytobrush or cervibroom or combination of two of these tools followed by transfer to a vial containing a fixative allows for follow up HPV testing when indicated · Primary goal of collective a Pap sample has always been to obtain cells from the endocervical/transformation zone region of the cervix 2 device combination is still the recommended Pap test collection method for both pregnant and nonpregnant women Pap test - liquid based cytology (ThinPrep, SurePath and MonoPrep) HPV DNA testing
Define/describe discomfort of pregnancy: Dyspnea
Common in 1st and 3rd trimesters. The increase in progesterone, starting in the 1st trimester, causes an increase in respiratory capacity, Vt, and RR causing SOB. In late third trimester, the uterus compresses the diaphragm, mechanically decreasing the capacity of the lungs to fully expand. This can increase shallow breathing--SOB. Late in third trimester, the sensation of SOB often decreases once the fetus engages into the pelvis. **Although lung function is more efficient during pregnancy, the sensation of feeling SOB can escalate to a feeling of panic for some.
Define/describe discomfort of pregnancy: Round Ligament Pain
Commonly seen in the late first trimester into the second trimester. The round ligaments suspend the uterus within the body. As the uterus expands in size and increases in weight, these ligaments are stretched like rubber bands. Nerve fibers that run next to the ligaments stretch along with them and can cause pain. This stretching can also produce a spasm of the round ligament that can result in sharp and sudden pain. Common symptoms are shooting pain after a sudden movement or sharp, knifelike pain in the lower abdomen or on one side, typically the right side, extending into the groin area.
Explain the effect of pregnancy on fat metabolism
Concentrations of lipids, lipoproteins and apolioproteins in plasma increase appreciably during pregnancy - - don't draw cholesterol levels Increased insulin resistance and estrogen stimulation during pregnancy are responsible for the maternal hyperlipidemia 1st & 2nd trimester = maternal fat accumulation 3rd trimester, fat storage declines or ceases This catabolic state favors maternal use of lipids as an energy source and spares glucose and amino acids for the fetus Maternal hyperlipidemia is one of the most consistent and striking changes of lipid metabolism during late pregnancy
Describe the interviewing techniques of a complete sexual history
Confidentiality (but mandated reporter) Do not make assumptions Orientation and sexual practices Consent Abuse Beliefs/culture Nonjudgmental Language of all clinic staff and nurses Body language/voice/facial expressions Use open-ended questions Use a diagram/model to discuss genital A & P
Define/describe discomfort of pregnancy: Constipation
Constipation is common early in pregnancy. Many factors contribute to the development of constipation including decreased peristalsis caused by relaxation of the smooth muscle of the large bowel in the presence of increased amounts of progesterone as well as changes in reabsorption. The displacement and compression of the bowel by the enlarging uterus or presenting part may also contribute to the deceased motility in the gastrointestinal tract and therefore, to constipation. One common s/e of iron medication is constipation. Dietary factors as well as a decrease in physical activity contribute to constipation
Contraceptive Patch
Contraindications: >198lbs should be counseled on addition forms of contraception - Benefits: decrease chance of endometrial, ovary cancer, cycle control is comparable to COCs, rapid reversibility - SE: Breakthrough bleeding with first two cycles, skin irritation, may fall off - 2x more risk then VTE then COCs - 150mcg of progesterone+ 20 mug of ethanol estradiol/day - suppresses gonadotropins and prevents ovulation, thickens cervical mucus
What are teratogenic disorders?
Teratogen is any agent or factor that induces or increases the incidence of abnormal prenatal development. Medications and environmental are common
Once the sperm has completely entered the oocyte, a reaction occurs that prevents another sperm from entering. What is it called?
Cortical reaction
Ethnic population screening (population, timing, meaning and appropriate follow-up) for Bloom Syndrome
Couples who are planning a pregnancy or who are already pregnant may decide to have testing to find out if they are carriers and at risk of having a baby with Bloom syndrome. It is standard of care to offer carrier screening to individuals of Ashkenazi Jewish descent for Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, mucolipidosis type IV, Niemann-Pick disease type A and Tay-Sachs disease. If both parents are found to be carriers, prenatal diagnosis by CVS or amniocentesis is available
Quad Screen
Done at 15-22 weeks AFP, Estriol, hCG and inhibin A Pos screen for Downs with all four increased Pos screen for trisomy 18: increased levels of AFP, Estriol, hCG Pos screen for NTD with elevated AFP
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Candidiasis
Diabetes is associated with increased incidence of VVC. VVC involves an overgrowth of normal flora and is not contagious. Symptoms include vaginal itching, burning, irritation, dyspareunia, and increased vaginal discharge. The vulva may read and swollen, and have areas of redness with satellite lesions extending from the affected area on external examination. The vagina is often red and slightly swollen. The vaginal discharge is thick white, and curd like, but it can also be thin and watery, or adherent to the vaginal walls. Treatment is with several OTC products...the "azoles." Probiotics and a garlic clove inserted vaginally has been known to help as well.
Define/describe discomfort of pregnancy: Epistaxis and nasal stuffiness
During pregnancy, the lining of the respiratory tract receives more blood, often making it more congested. This congestion can also cause stuffiness in the nose or nosebleeds. In addition, small blood vessels in the nose are easily damaged due to the increased blood volume, causing nosebleeds.Pregnancy rhinitis (defined as nasal congestion that lasts 6 or more weeks without signs of infection or allergy) is seen in up to 30% of all pregnant women and in approximately two thirds of those who smoke. These symptoms may appear anytime but usually begin in the second trimester and parallel increasing estrogen levels
What germ layer forms the central and peripheral nervous system, muscle, skin, hair and nails, mammary glands, pituitary glands and tooth enamel?
Ectoderm
What germ layer forms the lining of the gastrointestinal, urinary and respiratory tracts, linings of the ears, parts of the pancreas and thyroid?
Endoderm
How do you screen for endometrial cancer
Endometrial biopsy; takes a tissue sample of the endometrium from within the cervix
_____ peaks at ___ to ___ hours before ovulation
Estrogen; 24 to 36 hours
HIV Testing
Every pregnancy gets at first trimester unless opt out; without intervention the transmission is 15-40% with intervention it is 2%
The growth and development period is also known as what period?
Fetal period
Discuss impacts on sexuality during: Pregnancy
First Trimester Sexuality can be inhibited r/t nausea/vomiting, breast tenderness, fatigue, and anxiety Second Trimester Women often express heightened desire as they feel better; Some feel inhibited r/t weight gain or bodily changes Third Trimester May experience diminished sexual desire and activity r/t physical discomfort from increasing size May also be concerned about risk to fetus
Pap Smear/Cervical Cytology Screening
First pap at 21 years old regardless of sexual history Age 21-29 pap every 3 years unless abnormal Age 30+ contesting of HPV every 5 years if normal; every 3 years if abnormal pap with neg HPV
Define/describe discomfort of pregnancy: Flatulence
Flatulence and gas pain are another result of decreased GI motility. The slower transit time allows food a longer time for fermentation and gas production in the intestine. The decreased motility results both from the effect of progesterone relaxing smooth muscle and from the displacement of and pressure on the intestines by the enlarging uterus.
Describe the childbirth education method: Psychoprophylaxis - Lamaze
Focus: The six healthy birth practices: Let labor begin on its own; Move around and change positions; Have continuous support; Avoid interventions; Avoid being on your back; Keep mother and baby together. Number of classes: 6 weeks of classes taught by a Lamaze Certified Childbirth Educator.
Hematologic changes in folate requirements with pregnancy
Folate is a water soluble B vitamin that helps tissues grow and function properly. During pregnancy, folate requirements increase from 50-300/500mcg/day because of the growing fetus, increased maternal RBC mass and increased uterine size. Studies have demonstrated that adequate folate intake before and during pregnancy helps reduce occurrence of neural tube defects.
What are the three phases of the Ovarian Cycle:
Follicular phase Ovulatory Phase Luteal Phase
Labs at 35 to 37 weeks
GBS culture, GC/CT is positive earlier in pregnancy, possibly HIV and urine toxicology
What are the current recommendations for HPV vaccination
Gardasil: HPV type 6,11,16, and 18. Recommended age of vaccination is 11-12 years. Range: 9-26 years for both females and males. Cervarix: HPV types 16 and 18. Recommended age of vaccination is 11-12 years. Range: 10-25 years for females.
Ethnic population screening (population, timing, meaning and appropriate follow-up) for Gaucher Disease
Gaucher disease occurs at an increased frequency in individuals of Ashkenazi Jewish descent, with a carrier frequency of 1 in 15. It is a lysosomal storage disorder with variable severity that, if untreated, may result in anemia, hepatosplenomegaly, nosebleeds and fractures. In the more severe and rare form, the brain and nervous system are involved
Discuss the role of the midwife as genetic counselor and geneticist
Genetic history taking: Genetic screening done during the preconception period has the potential to positively impact pregnancy outcomes. A women's personal and family history should reveal any specific need for genetic screening/counseling based on race, ethnicity, and family history. Genetic counseling based on race/ethnicity and family history. A 3 generation history is recommended to identify recessive inheritance of problematic genes
Hormone(s) that the Hypothalamus Releases
GnRH
Sacrosciatic notch
Greater sacrosciatic notch: located between the posterior inferior iliac spine superiorly and the isch. Lesser sacrosciatic notch: bounded by ischial spine superiorly and the ischial tuberosity inferiorly.
calcifications of placenta
Gritty white surfaces - more common as placenta ages and with smoking
Name the 4 bony pelvis types
Gynecoid; Android; Anthropoid; Platypelloid
Oral Progesterone Side Effects
HA, emotional libility/depression, fatigue, acne, weight gain, decreased libido, breast tenderness, increased LDL, decreased HDL, melisma
Health implications and differences in screening, diagnosis and tx for STIs during pregnancy
HIV, Syphilis, HBsAG, - - 1st prenatal visit GC/CT with TOC @ 3-4 mths, HCV, Pap same as guidelines
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Chancroid
Haemophilus ducreyi Sx: ulcerative lesions in the vulva, cervix, or perineum PE: ulcerations, inguinal lymphadenopathy Screening: culture to r/o herpes, CT/GC and secondary infections, dark field microscopy to r/o syphilis, If lesion has been there > 7 days, do non-treponemal test for syphilis Tx for non-preg and pregnant: Azithromycin 1g PO once; Rocephin 250mg IM once; Erythromycin base 500mg PO TID x7d Sequalae - permanent scarring
Identify the hormones produced by the placenta and their function
HcG - The major function is to maintain the corpus luteum during early pregnancy in order to ensure secretion of progesterone and other substances until placental production is adequate. hPL - Promotes fetal growth by altering maternal protein, carbohydrate and fat metabolism. The main function of this hormone is to regulate glucose availability for the fetus Progesterone - acts to decrease myometrial activity and irritability; constrict myometrial vessels; decrease sensitivity of the maternal respiratory center to carbon dioxide; inhibit prolactin secretion; helps suppress maternal immunologic responses to fetal antigens, thereby preventing rejection of the fetus; relax smooth muscle in the gastrointestinal and urinary systems; increase basal body temperature; and increase sodium and chloride excretion; fetal glucocorticoid and and mineral corticoid production Estrogen - During pregnancy, estrogens act to enhance myometrial activity, promote myometrial vasodilation, increase sensitivity of the maternal respiratory center to carbon dioxide, soften fibers in the cervical collagen tissue, increase pituitary secretion of prolactin
Hcg in ectopic pregnancy
HcG does not rise at a doubling rate as in normal pregnancy
Influence of the hormonal shifts in pregnancy
Hcg increases in early pregnancy to sustain estrogen and progesterone levels for corpus luteum until placenta takes over Hpl - human placental lactogen - ensures fetal nutrition by altering maternal glucose metabolism and allowing for fetal uptake Progesterone - needed to maintain pregnancy, produced by corpus luteum until 7-9wks gestation then produced by placenta (luteal placental shift) Estrogen - increase uterine blood flow, promote growth
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Hepatitis B
Hepatitis B Virus (HBV) is a bloodborne pathogen transmitted by percutaneous or mucosal exposure to infectious blood or body fluids (including blood, saliva, tears, vaginal secretions, and semen); Rashes, jaundice in conjuctiva, englargement and tenderness of liver, weight loss, fever, arthralgias, fatigue, nausea, vomiting, anorexia, abdominal pain, clay-colored stools, dark urine; Hep B immunoglobulin within 24 hrs for definite exposure
Ovulatory Phase
High levels of progesterone and LH causes synths of prostaglandins and proteolytic enzymes which break down the follicular wall and lead to the explosion of the ovum; the ovum is then drawn up by the ciliated fimbriae of the fallopian tube to initiate its migration through the oviduct
Sacrococcygeal joints
Hinge joint between the sacrum and the coccyx, at the end of labor allow the coccyx to be deflected backwards facilitating delivery.
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: genital warts
Human Papiloma Virus (specifically types 6 & 11). Virus is transmitted by genital, vulvar, perineal, or rectal contact; Fleshy papules, pedunculated warty lesions on vulva, introitus, perineum, anus, cervix, and vaginal walls;
What are some common autosomal dominant inheritance
Huntington disease. Achondroplasia (dwarfism) Marfan syndrome. Neurofibromatosis
What is the significance of a heavy placenta
Hydrops placenta/fetalis Macrosomia, infant of diabetic mother Beckwidth-Weidemann syndrome Triploidy
Describe the childbirth education method: Hypnobirthing
HypnoBirthing is a unique antenatal program that teaches simple but specific self-hypnosis and relaxation techniques for an easier, more gentle birth that is often accompanied by a significant reduction in pain. HypnoBirthing is not about "training mothers to give birth". HypnoBirthing is about getting rid of fear and allowing our bodies and minds to relax so we can birth our babies gently.
What is the relationship of HPV to abnormal pap smear results
If test result reflects the presence of atypical squamous cells of undetermined significance, it is recommended that HPV DNA testing be implemented · Testing is negative, repeat pap testing at 12 mths · Testing is positive for high risk DNA, then follow up colposcopy If low-grade squamous intraepithelial lesions results in postmenopausal period, then HPV DNA testing should take place and repeat pap testing in 6 and 12 months or colposcopy · If high risk is or HPV test is negative, then repeat pap testing in 12 months Once 2 consecutive negative cytologic results are obtained, then woman can return to recommendation for >65 yrs
What are some causes of a FALSE POSITIVE reaction to a PPD?
If the patient has had a TB infection in the last 8-10 weeks The TB infection occurred many years ago If the patient has a weakened immune system and the cutaneous tissue is not able to react to the skin test If the patient is less than 6 months old The patient has recently received a live virus vaccination (measles and smallpox would be examples) or has had a recent viral illnesses such as measles and chicken pox
nutrition in pregnancy
Impacted by preexisting nutritional status/ habits, past experiences, psych factors (unplanned preg., stressors, SES), overall health/ preexisting problems, discomforts of pregnancy (N/V, constipation), myths/ misconceptions
What are legal issues relevant to pregnancy with the LGBTQ population?
In the case of a known donor, mothers may be concerned about their child having the ability to locate the donor at a time later in life; concerns about the donor making a claim for parental rights. A lesbian couple may have to identify the legal relationship between the "social (non-biological) mother" and the child. Second parent adoption may or may not be legal for lesbian or gay couples. Depends on the state
Describe breast changes during pregnancy
In the first few weeks of pregnancy women often experience breast tenderness and paresthesias. After 8 weeks gestation the breasts increase in size, and delicate veins become visible beneath the skin. The nipples become larger, darker, and more erectile. The areola are broader and darken. Colostrum (a thick yellowish fluid) can be manually expressed after a few months. Striae may develop on the breasts as well as the abdomen
What is associated with long or hypertwisted umbilical cord
Increased fetal activity Polyhydramnios Heart failure (increased distance to pump) Increased risk of cord accident
Define/describe discomfort of pregnancy: Edema
Increased vascular permeability and sodium retention due to the effects of estrogens and corticosteroids result in transient nonpitting edema of the face, hands, and feet during late pregnancy. In the lower extremities, this is aggravated by pressure from the growing uterus. Nonpitting edema occurs in the face, especially the eyelids in approximately 50% of women, and in the lower extremities in 70% and is not associated with preeclampsia.
Urine Toxicology Screen
Indicated with history or loss of custody of children, altered mental status, s/s of intoxication or withdrawal, placental abruption, physical evidence of drug abuse
Ethnic population screening (population, timing, meaning and appropriate follow-up) for Canavan Disease
It is a JGD -- frequency of carrier in Ashkenazi Jewish population is 1/40; disease frequency in Ashkenazi Jewish population is 1/6400 - 1/13500. This population should be tested for carrier status ideally preconception. Test the partner with Ashkenazi Jewish ethnicity first. Testing is by direct DNA testing of blood, saliva, or skin cell samples. Genetic counseling after carrier status is confirmed is recommended.After conception, can acquire cells for diagnostic testing of the fetus via amniocentesis at 15+ weeks. Can send samples for direct DNA testing.
Ethnic population screening (population, timing, meaning and appropriate follow-up) for Mucolipidosis IV
It is a lysosomal storage disorder that results in psychomotor retardation, ophthalmic disorders and a maximum developmental age of 1 to 2 years
About 5 days after fertilization, what occurs with the blastocyst?
It will shed the zona pallucida and secrete substances that help to make the uterine lining even more receptive to implantation
What are methods of achieving pregnancy for LGBTQ?
LGBT family building also requires third-party reproduction services in the form of egg donors sperm donors, or gestational carriers (surrogates). Family planning for lesbian couples typically includes intrauterine insemination (IUI) or In-Vitro Fertilization (IVF). Same-sex female couples will also need an anonymous or known sperm donor.
What are considerations for LGBTQ patients at the institutional level?
LGBT people with health insurance, gaining access to the appropriate care can still pose difficulties. For instance, a transgender individual will not be covered for any procedure or cancer screenings that are inconsistent with the gender marked on the insurance card, such as a pap smear for a transgender man with an intact cervix.
small, light placenta
Less than 10% for GA - may be associated with intrauterine infections, genetic mutations, or HTN
Define/describe discomfort of pregnancy: Leukorrhea
Leukorrhea is a profuse, thin or thick vaginal secretion that typically begins during the second trimester. The secretion is acidic because of the conversion of glycogen in the vaginal epithelial cells into lactic acid by lactobacilli. The productivity of the cervical glands in secreting more mucus at this time to form the cervical mucus plug may also contribute to leukorrhea. An increase in vaginal discharge may be a sign of vaginitis, either secually transmitted or not, ruptured membranes, or permature labor.
Station
Location of the baby's presenting part as it moves through the pelvis
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: PID
Lots of transmitted organisms: N. gonorrhoeae and C. trachomatis, G. vaginalis, Haemophilus Symptoms: may be asymptomatic, or abnormal bleeding, dyspareunia, and vaginal discharge), others include: cervical motion tenderness, uterine tenderness, adnexal tenderness. Dx: WBCs present on wet prep Screening: if dx with PID, then screen for HIV, as well as gonorrhea and chlamydia Pregnancy: Pregnant women suspected to have PID are at high risk for maternal morbidity and preterm delivery. These women should be hospitalized and treated with intravenous antibiotics Tx: Ceftriaxone, Doxycycline, Metronidazole
Define/describe discomfort of pregnancy: Striae gravidarum
Many women develop these pink or red streaks during pregnancy. Silvery white streaks may be present from previous weight changes or previous pregnancy.Striae are linear tears in dermal collagen that are commonly seen during pregnancy. These markings initially appear as irregular, pink or purple, wrinkled linear streaks that gradually become white. Striae are most prominent by 6-7 months and occur in 50-80% of pregnant women.
Who is "The Mother of Nurse Midwifery"
Mary Breckenridge
2nd Trimester Screening for Aneuploidy (Quad Screen)
Maternal serum second trimester screening is used to screen for Down syndrome, trisomy 18, and neural tube defects (spina bifida and anencephaly). Some infants with Turner syndrome may also be identified. AFP and hCG are most useful in screening for Down syndrome, whereas AFP is most useful for screening for neural tube defects
What germ layer forms the connective tissue, cartilage, bone, striated and smooth muscle, heart, blood, lymphatic system, kidneys, ovaries, testes, spleen, and adrenal glands?
Mesoderm
How is the diagnosis of down syndrome made
Metaphase analysis of cultured amniocytes or chorionic villus cells is the preferred method for karyotype analysis Amniocentesis (15-20 weeks gestation) Fetal cells are obtained from amniotic fluid that is withdrawn from the amniotic sac. Fetal chromosomes are contained within these cells; they can be analyzed to look for both structural and numerical abnormalities. Chorionic villus sampling (10 weeks - 12 weeks 6 days gestation) Chromosomal abnormalities by obtaining a sample of chorionic villi cells from the placenta
Midwives v. Physicians
Midwives: protect normal physiology of labor, require safe mechanism for consultation, collaboration, and referral -risk factors v. actual complications -no IVs in birth centers -woman is active partner in shared decision making
How would you counsel someone inquiring about the HPV vaccination
More than 40 types of human papillomavirus affect the genital tract, but only a few types are considered to pose a high risk for the development of cervical cancer. Types 16,18, 31, 33, and 35 are associated with cervical dysplasia and can contribute to the development of anal, cervical, penile, and vulvar cancers. Recently developed HPV vaccines are important preventive strategies for young women and young men to guard against these infections.
large, heavy placenta
More than 90% for GA - due to various maternal conditions i.e. maternal diabetes, fetal erythroblastosis, fetal hydrops, fetal congestive heart failure, and maternal-fetal syphilis
By about 3-4 days after fertilization, a ______ (a mulberry-like group of cells) made of 12-32 cells enter the uterine cavity.
Morula
Define/describe discomfort of pregnancy: Heartburn
Most common in 3rd trimester. two key factors: pregnancy hormones and uterine growth. Increased estrogen and progesterone cause the lower esophageal sphincter to relax allowing stomach acid to flow back up causing burning and pain. As uterus grows, it crowds the stomach and intestines causing the stomach and acid to back up into the esophagus. Eat 5-6 meals to facilitate digestion avoid overloading the stomach at one time.
Explain the effect of pregnancy on carbohydrate metabolism
Normal pregnancy is characterized by mild fasting hypoglycemia, postprandial hyperglycemia and hyperinsulinemia Pregnancy induced state of peripheral insulin resistance, the purpose of which is likely to ensure a sustained postprandial supply of glucose to the fetus Progesterone and estrogen may act directly or indirectly to mediate this insensitivity
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: NGU
NGU is confirmed in symptomatic men when staining of urethral secretions indicates inflammation without Gram negative or purple diplococci. All men who have confirmed NGU should be tested for chlamydia and gonorrhea Tx: Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days Men treated for NGU should be instructed to abstain from sexual intercourse until they and their partner(s) have been adequately treated (i.e., for 7 days after single-dose therapy or until completion of a 7-day regimen and symptoms resolved). Men who receive a diagnosis of NGU should be tested for HIV and syphilis
What are the reporting and confidentiality regulations for STIs?
Nationally notifiable STIs include chancroid, chlamydia, gonorrhea, hepatitis, HIV, and syphilis. Additionally, individuals with STIs should be asked to identify and notify all partners who might have been exposed to the infection. The patient must be informed when a case will be reported and told why. Failure to inform the patient that the case will be reported is considered a serious breach of professional ethics.
Ethnic population screening (population, timing, meaning and appropriate follow-up) for Niemann-Pick Disease Type A
Niemann-Pick disease type A occurs at an increased frequency in individuals of Ashkenazi Jewish descent, with a carrier frequency of 1 in 90. It is a lysosomal storage disorder that results in poor growth, hepatosplenomegaly, progressive mental and physical deterioration and death by 4 years of age. Couples who are planning a pregnancy or who are already pregnant may decide to have testing to find out if they are carriers and at risk of having a baby with Niemann-Pick disease type A
What client factors can affect the quality and interpretation of cervical cytology
No sex or vaginal intercourse for 48 hrs before pap because of presence of sperm Liquid testing remove some of these sample errors
Define/describe discomfort of pregnancy: Nocturia
Nocturia also can be caused by increased urine production at night. Additionally, pregnant women have an increase in sodium excretion at night, with an associated increase in fluid excretion,which may also explain nocturia.
Cell free DNA testing
Noninvasive prenatal testing is the newest testing option for identification of trisomies, 21, 18, and 13, but is not yet widely available. NIPT involves collection of maternal blood, which contains small fragments of circulating cell-free fetal DNA, anytime after 10 weeks gestation. This newest technology amplifies the fetal DNA and makes it possible to quite accurately identify the extra genetic material that exists when aneuploidy is present in the fetus
1st Trimester Screening for Aneuploidy
Noninvasive screen (11 - 14 weeks) •The most effective first trimester biochemical markers are PAPP-A levels are reduced, hCG increased, and the NT measurement increased in trisomy 21. Invasive DIagnostic (10-13 weeks) •CVS can be performed by either a transcervical or transabdominal approach
Ethnic population screening (population, timing, meaning and appropriate follow-up) for Cystic Fibrosis
Northern europeans - 1/25 carrier frequency; 1/2500 newborn incidence
Ultrasound for defects
Nuchal translucency by US at 11-13 weeks gestation Fetal anomaly scan between 16-20 weeks gestation
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Urethritis
Organism: E coli, N gonorrhoeae, C trachomatis, HSV Sx: urinary frequency, difficulty starting urination, dysuria, urethral/ vaginal discharge, blood in semen or urine PE: mucopurulent or purulent urethral discharge, urethral smear with 5+ leukocytes, first voided urine specimen that has leukocyteresterase on dipstick or at least 10WBC/ hpf on microscopy. Screen only if symptomatic Diagnose with PE, GC/ CT, discharge with microscopy Tx: Ceftriaxone 250mg IM in single dose PLUS azithromycin 1g PO in single dose Sequelae include strictures, stenosis, PID, and abscess formation
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: HIV
Organism: Human immunodeficiency virus Sx: often asymptomatic, flu like sx (fever, sore throat, fatigue are usually first sx) PE: lymphadenopathy, opportunistic infections (oral candidiasis) Screening: pts 13-64 seen in healthcare setting, pts seeking tx for STIs, pts initiating tx for TB, patients who have had sex with > 1 partner since last HIV screening, those with occupational exposure to blood and body fluids, pregnant women, IV drug users and their partners, those who exchanges sex for money or drugs, sex partners of HIV + people, those considering having a new sexual partner, MS with > 1 partner since last HIV screening Encourage contraception (depo and condoms preferred) Pregnancy: Antiretrovirals can cause NTD and fetal anomalies C/S decreases risk of vertical transmission. Discourage breastfeeding in areas where there is adequate access to food.
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Granuloma Inguinale
Organism: Klebsiella granulomatis Sx: painless, beefy-red lesions that bleed on contact and spread. Subcutaneous granulomas form under the skin in inguinal area PE: ulcerative lesions, can be hypertrophic or necrotic. Lymphadenopathy (local or regional), purulent exudate with secondary infections Screening: r/o other causes → HSv culture for secondary bacterial infection, dark field microscopy for T. pallidum, non treponemal testing for syphilis Tx: Doxycycline 100mg PO BID for 21d Pregnancy: erythromycin base 500mg PO 4x/day x21d Treat all sexual partners of the last 60 days
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Syphilis
Organism: Treponema pallidum Sx: often asymptomatic or can mimic other conditions Primary: chancre (non-tender, filled with purulent discharge) Secondary: change from local to systemic infection → rash on palms of hands, soles of feet, and trunk Screening: Non treponemal tests (VDRL, RPR), confirm with treponemal test Tx: Primary: benzathine penicillin g 2.4 million units IM in single dose Latent >1yr: benzathine penicillin g 2.4 million units IM in 3 doses each at 1 week intervals Can cause congenital anomalies if untreated: deafness, hepatomegaly, bone abnormalities, IUFD, large pale placenta
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Proctitis, proctolitis, and enteritis
Organism: usually GC/CT Sx: rectal fullness, rectal/ anal pain, diarrhea, urge to have bowel movement, LLQ abd pain, passing mucus through rectum, rectal bleeding PE: mucosal erythema, mucosal friability, vesicles/ ulcers, painless chancres, hemoccult + stool, telangiectasis, elevated fecal calprotectin and fecal lactoferrin, possibly tender inguinal lymph nodes. Dx: rectal swabs for GC/CT, VDRL and dark field microscopy to r/o syphilis Tx: antibiotics, antivirals, corticosteroids, GI agents Follow up with colorectal surgeon to monitor progress clinically and endoscopically and follow results of cultures, labs, and biopsies Sequelae: chronic ulcerative colitis, fistula formation, abscess, perforation
Describe the barriers to obtaining a complete sexual history
Our own biases and discomforts get in the way of taking a sexual history. Clinicians barriers include: not seeing the woman's sexual history as relevant to her health problem, inadequate training, embarrassment and fear of offending.
Sickle Cell Disease
SS, SC (less severe); also pt taking 4mg of folic acid and follow up with FOB screening
Recommended Daily Dietary allowance
P=pregnant, L= lactating -Vit A: 770ng(P), 1300 (L) -Vit D: 600IU (P), 600IU (L) -Vit E: 15mg(P), 19mg (L) -Vit K: 90ng(P), 90ng(L) -Vit C: 85mg(P), 120mg(L) -Thiamin: 1.4mg(P), 1.4mg(L) -Riboflavin: 1.4mg(P), 1.6mg(L) -Niacin: 18mg(P), 17mg(L) -Vit B6: 1.9mg(P), 2mg(L) -Folate: 600ng(P), 500ng(L) -VitB12: 2.6ng(P), 2.8ng(L) -Calcium: 1000mg(P), 1000mg(L) -Phosphorus: 700mg(P), 700(L) -Iron: 27mg(P), 9mg(L) -Zinc: 11mg(P), 12mg(L) -Iodine: 220ng(P), 290ng(L) -Selenium: 60ng(P), 70ng(L)
Recommendations for tx of syphilis in pregnant women with penicillin allergy
PCN G is the only acceptable tx for syphilis in pregnancy If the woman is PCN allergic, desensitize her per CDC guidelines
Escutcheon
Pattern of pubic hair
Changes in the fluid and electrolyte balance with pregnancy
Pregnancy is characterized by increases in components of the renin-angiotensin-aldosterone system and decreased sensitivity to the pressor effects of angiotensin II. The increased aldosterone opposes the sodium losing effects of progesterone and allows a progressive accumulation of sodium in maternal and fetal tissues. Because ECF volume is determined by sodium, the accumulation of sodium in pregnancy is accompanied by accumulation of water. Both extracellular and intravascular volumes expand during pregnancy.
What is PLISSIT model of sexual counseling
Permission ( at every step) Limited information Specific suggestions Intensive therapy Reflection and review at every step
Describe the childbirth education method: Husband-coached childbirth (Bradley)
Philosophy: Teaches families how to have natural births. Techniques are based on how the human body works in labor. Focus: What to expect and how to avoid pain in labor, focusing on a healthy pregnancy and the relationships of the pregnant woman and her support people. Number of classes: 12 classes that follow a workbook with a certified instructor.
Explain the effects of pregnancy on the endocrine system
Pituitary gland enlarges by 135% - - d/t estrogen stimulated hypertrophy and hyperplasia Growth Hormone ○ 1st trimester - secreted form maternal pituitary gland; By 17 weeks, the placenta is the principal source of growth hormone secretion Maternal plasma prolactin levels increased markedly during normal pregnancy and concentrations are usually tenfold greater at term Thyroid - Increases production of thyroid hormones by 40-100%
What is associated with a short or flat umbilical cord
Poor fetal activity Neuromuscular compromise Oligohydramnios Associated with limb/body wall complex, gastroschisis
Define/describe discomfort of pregnancy: Leg Cramps
Potential causes include hormonal and biochemical changes of pregnancy affecting the calcium, magnesium, and phosphorus levels or the ability of calcium to enter the muscles. suggests that the enlarged uterus exerts pressure either on the pelvic blood vessels, thereby impairing circulation. Pregnancy is a known cause of secondary restless leg syndrome;
Ethnic population screening (population, timing, meaning and appropriate follow-up) for Spinal Muscular Atrophy
Preconception and prenatal screening is not recommended in the general population at this time It should be offered to those with a family hx of SMA or SMA-like disease and those who request SMA carrier screening and completed genetic counseling
Anatomic changes in kidneys, ureters and bladder with pregnancy
Pregnancy is characterized by physiologic hydroureter and hydronephrosis with significant dilatation of the renal calyces, pelvis, and ureters beginning as early as the seventh week. The mean kidney length increases by approximately 1cm due to the increased renal blood flow and vascular volume and the renal hypertrophy. Renal volume increases by 30%. The ureters elongate and become more tortuous during the last half of pregnancy as the are laterally displaced by the growing uterus. Bladder changes include filling frequency due to increased blood flow and pressure from growing uterus
Discuss emotional and psychosexual changes during pregnancy
Pregnant women experience a range of emotions throughout the prenatal course from joy and excitement to ambivalence, fear, and anxiety, sometimes all on the same day. The physical changes and pregnancy discomforts and the tremendous hormonal influences play a role in a pregnant woman's emotions. Pregnant women often report having detailed and vivid dreams that often reflect anxieties and concerns about pregnancy or parenting. These emotional changes are normal and universal across cultures in pregnant women.
What are the goals of prenatal education
Prenatal health education needs to be tailored to the woman's needs, with a focus on health literacy, health numeracy, and cultural sensitivity. Teaching should be focused first on acute needs, such as "warning signs" of obstetric complications, counseling about genetic tests, and ways to reach the midwife. Among the topics are food safety, planning for birth, childbirth preparation classes, postpartum contraception
Ethnic population screening (population, timing, meaning and appropriate follow-up) for Sickle Cell Anemia
Prenatal testing for sickle cell can also be done by testing the amniotic fluid when the fetus is 14-16 week old. identify the presence of hemoglobin S, to evaluate the status and number of a person's red blood cells (RBCs) as well as hemoglobin level, and/or to determine whether a person has one or more altered hemoglobin gene copies.
Describe the childbirth education method: Birthing from Within (England)
Prevent or minimize emotionally difficult births (for parents and professionals) through compassionate, honest preparation. Childbirth is a profound rite of passage, not a medical event (even when medical care is part of the birth). The essence of childbirth preparation is self-discovery, not assimilating obstetric information. The teacher (mentor) is "midwife" to the parents' discovery process, not the expert from whom wisdom flows.
Define/describe discomfort of pregnancy: Hemorrhoids
Progesterone causes relaxation of the vein walls in recturm - predisposes woman to developing hemorrhoids. Constipation and excessive straining adds to risk. Enlarging uterus causes increasing pressure on hemorrhoidal veins; Should also make sure patient does not report abdominal pain, changes in stool color (black, tarry), diarrhea, rectal bleeding - further investigation into GI disorders. Comfort measures: avoid constipation/straining during defacation, Sitz baths, ice, witch hazel compresses, Epsom salt compresses, topical anesthetics, topical cortisone creams
Describe anatomic effects of pregnancy on the musculoskeletal system
Progressive lordosis is a characteristic feature of normal pregnancy. Compensating for the anterior position of the enlarging uterus Shifts the center of gravity back over the lower extremities Sacroiliac, sacrococcygeal and pubic joints have increased mobility during pregnancy
What are the three phases of the Endometrial or uterine Cycle?
Proliferative phase Secretory phase Ischemic/Menstrual phase
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Pediculosis Pubis
Pubic lice differ from head lice by their "crab-like" look and have a lower length to width ratio than head lice. Dx is made by inspection of all areas, lice and nits are visible on hairs; small punctuate lesions and bluish macules may be seen. Tx: Non-Pregnant and Males: Premethrin cream 1% rinse (NIX) - apply to affected area leave on 10 minutes and rinse off or Premethrin with piperonyl butoxide (RID) apply to affected area and leave on 10 mins then rinse off. Ivermectin (stromectol) 250 mg/kg orally. Recommended tx for pregnant women or breastfeeding women: Premethrin cream 1% (NIX) or RID - - Malathion (Ovide) is contraindicated in pregnancy and during lactation.
Hematologic changes in RBCs with pregnancy
RBC mass will increase by 20-30% by the end of a normal pregnancy; which occurs because of increased production of RBCs, secondary to increased production of RBCs in the bone marrow. Human placental lactogen (hPL), progesterone and prolactin have been identified as the hormones of pregnancy that stimulate an increase in erythropoiesis
What qualifies a women for Rhogam and when does she receive Rhogam?
Rh(-) at first prenatal should be retested at 24 to 28 weeks. Titer > 1:4 suggest positive antibody test; Rhogam at 28 weeks and within 72 hours of delivery (can be given up to one month PP); Rhogam to be given after chronic villi sampling, with trauma or with misscarriage; Rhogam prevent Anti D antibody formation
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Hepatitis A
RNA virus transmitted through the fecal-oral route and most cases are part of community wide outbreaks, contaminated water and food (especially shellfish) are common sources of infection, with most cases being associated with close personal contact with an infected person, although blood-borne transmission has been documented; Some people with Hep A do not have symptoms but may be the following: fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay colored BM, joint pain, jaundice; Incubation period of 28 days (range 15-50 days), with the virus being shed through the feces approximately two weeks prior to the emergence of clinical symptoms
Platypelloid Pelvis
Rare <3% of women - widest of all types and is shallow Outcome: NOT conducive to vaginal birth, unable to accomodate rotation and descent of fetal head Inlet: flat Sacrum: inclined posteriorly and quite hallow Pubic arch: quite wide
Clinical Breast Exams
Recommended in 20s to 30s every 1 to 3 years and after 40 yearly
Define/describe discomfort of pregnancy: Awkward Gait
Relaxin and progesterone affect the cartilage and connective tissue of the sacroiliac joints and the symphysis pubis. Along with external rotation of the femurs, increases the mobility of these joints and leads to the characteristic "waddle" gait seen in many pregnant women. Widening and increased mobility of the sacroiliac synchondrosis and symphysis pubis begins by 10 to 12 weeks. The symphysis pubis may widen up to 10mm
Describe the questions to be asked to take a complete sexual history
Remember the 5 P's: Partners, Prevention of Pregnancy, Protection of STI's, Practices, and Past hx of STI's Age at first coitus Sexually active (yes/no) If yes, then gender preference (men, women, or both) and # of partners in the last few months Monogamous with current partner (yes/no) Comfortable with frequency and types of sexual activity (yes/no) Patterns of sexual behavior (frequency and types of practice)
Health implications and differences in screening, diagnosis and tx for STIs for adolescents
Routine screening for Chlamydia and Gonorrhea on an annual basis for all sexually active females <25 years old HIV should be discussed and offered to all adolescents - frequency of repeat screenings of those at risk for HIV infection should be based on level of risk Routine screening in asymptomatic adolescents for syphilis, trich, BV, HSV, HPV, HAV, and HBV not generally recommended - pregnant teens should receive syphilis screening
What are recommended screening tests for LGBTQ patients?
STIs and HIV - the incorrect assumption is that lesbian partners have never had sex with men which is not always the case, some STIs can also be transmitted via same sex partners. Bacterial vaginosis, candidiasis, herpes, and human papillomavirus infections, can be contracted by lesbians; no reported cases of HIV spread between lesbian partners, but bisexuals have a higher risk Lipid profile, diabetes screening - studies show lesbian partners are at increased risk for alcohol and obesity Cervical Cancer screenings based on recommended age - - lesbian partners are at risk for
Colorectal Cancer Screening
Screen between ages 50-75 Fecal occult blood testing yearly beginning at age 50 Colonoscopy every 5 years starting at 50 years old
Environmental Exposures
Screen for exposures to -lead -toxic household chemicals (oven cleaners) -metals: mercury/ cadmium/ arsenic (near manufacturing/ mining areas) -pesticides -high chlorine levels and other water chemicals -organic solvents (paint thinners, photography, silk screening)
2nd Trimester Screening for Aneuploidy (Triple Screen)
Second trimester screening is called maternal serum multiple marker screening, enhanced or expanded maternal serum AFP screening, triple screen, or quad screen depending on the components used. Screening is done on maternal serum at 15-20 weeks, optimum is 16 to 18.5 weeks.
Define/describe discomfort of pregnancy: Taste/smell distortion
Self-reported abnormal sensitivity, qualitative distortions and phantom sensations with respect to smell and taste was assessed with a longitudinal design, based on questions referring to gestational weeks 13-16 and 31-34 of pregnancy in comparison with 9-12 weeks post partum and with non-pregnant women with corresponding time durations and intervals.
Rectovaginal septum
Separate the vagina from the rectum, can tear during childbirth
Define/describe discomfort of pregnancy: Libido Changes
Sexual activity often declines during the first trimester due to the normal pregnancy symptoms of fatigue, sore breasts, emotional liability, and nausea. fears of miscarriage can also decrease sexual desire. During the second trimester, women may find an increase in sexual desire as first trimester discomforts cease; Women may report feeling more erotic and energetic, and fears of miscarriage may subside. Increased genital blood flow and lubrication may make organsm easier to acienve. During the third trimester, physical discomforts and the gravid abdomen may make traditional sex acts less appealing.
What questions/test do you ask/do for someone coming in wanting an STI screen?
Sexual partners, HSV lesions noticed, hep B shots?, test for g/c, syphilis and HIV
Describe the mechanism by which substances cross the placenta
Simple Diffusion: transfer of substances across the membrane down a concentration gradient (area of higher concentration to area of lower concentration) → includes O2, CO2, electrolytes, water, certain medications (analgesic and anesthetic agents) Facilitated Diffusion: transfer of substances across the membrane down a concentration gradient but in a manner that allows for more rapid/ specific transfer → glucose (essential for rapid fetal growth but present in low concentrations in maternal blood) Active transport: transport against concentration gradient. Requires energy → transfer to fetus of substances that are in higher concentrations in the fetus than in the mother (ascorbic acid) Pinocytosis: endocytosis that allows small particles to be brought into cell. cell membrane folds around particle and becomes intracellular membrane → IgG globulin maternal antibodies, phospholipids used to make cell membranes, lipoproteins used to transport cholesterol
Ischial tuberosities
Sit bones, lower part of ischium.
Define/describe discomfort of pregnancy: Sciatica
Some women experience pelvic girdle pain that may or may not be assoc with back pain: referred to as "sacroiliac joint pain". Can be misdiagnosed as sciatica--only 1% of pregnant women have true sciatica
Define/describe discomfort of pregnancy: Ptyalism
Some women may have the sensation of ptyalism (hypersalvation) related to a reluctance to swallow saliva during periods of nausea and vomiting, but in some cases a woman will have an actual increase in saliva production. Because ptyalism is often associated with nausea vomiting, the differential diagnoses include hyperemesis gravidarum and GERD. Ptyalism usually resolves spontaneously although resolution may not occur until after the pregnancy is over.
What determines the gender of the embryo?
Sperm by either contributing an X for female or Y for male sex chromosome
Vaginal Ring (back up method/starting method)
Start on first day of cycle, cycle day 2-5 can start but should use alternate form of contraception first 7 days of ring use
Describe changes in the gastrointestinal tract due to the anatomical changes of pregnancy
Stomach moved superiorly, intestines displaced laterally, gastric emptying and motility decreased secondary to smooth muscle relaxation effects of progesterone. Constipation common in 1st tri when growing uterus puts pressure on descending colon; heartburn common in 2nd and 3rd trimester
Sacroiliac joints
Strongest joints of the body, connect the spine to the pelvis. Formed where the ileum joins with the first two sacral vertebrae.
Define/describe discomfort of pregnancy: Dizziness/syncope
Supine hypotensive syndrome causes the woman to feel dizzy and lightheaded. Supine hypotensive syndrome occurs when the woman lies in a supine position and the full weight of the enlarged uterus and its contents rests on the inferior vena cava and other vessels of the venous system. Venous return from the lower half of the body is inhibited, which in turn reduced the amount of blood filling the woman's heart and subsequently lowers her cardiac output. Supine hypotensive syndrome is actually arterial hypotension. Supine hypotensive syndrome is alleviated immediately by simply having the woman either turn on her side or sit up.
False Negative PPD can occur if...
TB infection in last 8-10 weeks, TB infection occurred many years ago, weakened immune system so skin won't react, less then 6 most old child, recent live virus vaccine (MMR, smallpox), or recent viral disease infection (Chicken pox), incorrect admin or interpretation
Tuberculin Skin Test (PPD)
TB testing PPD> 5 = + if HIV+, recent contact of known TB case, fibrotic change on CXR, taking immunosuppressive tx for >1 month PPD>10= + in recent immigrant, IVD users, live or work in LT care facility, certain medical conditions, children under 4 PPD>15= + in all circumstance unless BCG received in last 5 years PPD >20= +
Coccyx
Tail bone, lower part of spine, composed of four rudimentary vertebrae. Gives attachment to ligaments, deep muscles of pelvic floor and to muscle fibers of the anal sphincter. During labor moves backwards.
coccyx
Tail bone, lower part of spine, composed of four rudimentary vertebrae. Gives attachment to ligaments, deep muscles of pelvic floor and to muscle fibers of the anal sphincter. During labor moves backwards.
Ethnic population screening (population, timing, meaning and appropriate follow-up) for Thalassemia
Thalassemias are Mendelian autosomal recessive inherited disorders of the globin chains that form normal adult hemoglobin (hgb A) Alpha-thalassemia is most common among individuals of Chinese and Southeast Asian descent Beta-thalassemia most common among women of Mediterranean origin and to a lesser degree among Chinese, Asian, and African women Pregnant women who are of Southeast Asian or Mediterranean descent should be screened for thalassemia if they have anemia, normal iron indices, and a low mean corpuscular volume (MCV)
Identify the origin of amniotic fluid throughout pregnancy
The amniotic sac that contains the baby and begins to form about 12 days after conception. Amniotic fluid begins to form at that time, too. In the early weeks of pregnancy, amniotic fluid is mainly made up of water supplied by the mother. After about 20 weeks, the baby's urine makes up most of the fluid.
Spiral arteriole
The blood supply to the uterus comprises a branched structure with successive decreases in vessel diameter as they progress through the myometrium and endometrium. Spiral arteries, so called because of their coiled appearance, supply blood to the endometrial layer and, in the pregnant uterus, span the inner myometrium and the decidua.
Define/describe discomfort of pregnancy: Breast enlargement, tingling and tenderness
The breasts undergo significant changes secondary to the effects of estrogen, progesterone, prolactin, hCG, and HPL. The fat layer of the breasts thickens, and there is proliferation and differentiation of the ductal system and glandular tissues of the breasts. Blood flow increases, and it is common for the blood vessels of the breast to appear more prominent when inspecting the breasts. The breasts increase in size and weight, causing many women to experience breast heaviness and/or breast tenderness.
Define/describe discomfort of pregnancy: Numbness and tingling of finers and toes
The change in the center of gravity resulting from the enlarged and heavy uterus may cause the woman to assume a posture in which her shoulders, neck, and head are out of the normal alignment. This places pressure or traction on nerves in the arm, which can cause tingling and numbness of the fingers. Physiologic edema can also exert pressure on the nerves supplying the hands, which can cause numbness or tingling or exacerbate preexisting problems such as carpal tunnel syndrome. Treatment is designed to alleviate symptoms and consists of wrist splints that keep the wrist in a neutral position and are worn while sleeping during work or other activities.
Atresia
The degeneration of the remaining eggs that do not get released for fertilization in the reproductive years of life
Describe the vasculature changes of the uterine cavity during pregnancy
The delivery of most substances essential for fetal and placental growth metabloism and wast removal is dependent on adequate perfusion of the placental intervillious space. Placental perfusion is dependent on total uterine blood flow, and simulataneous measurement of uterine, ovarian, and collateral vessels. Uteroplacental blood flow increases progressively during pregnancy. Estimates range from 450-650ml/min near nerm. Uterine veins adapt during pregnancy. Venous remodeling includes reduced elastin content and adrenergic nerve density. This creates increased venous caliber and distensibility. Uterine artery diameter doubled by 20 weeks which increases velocity approximately 8 fold.
Describe the mucosa changes of the uterine cavity during pregnancy
The endocervical mucosal cells produce copious tenacious mucus that obstruct the cervical canal soon after discusion. This mucus is rick in immunoglobulins and cytokines and mayact as an immunological barrier to protect the unterine contents against infection. At the onset of labor, if not before, this mucous plug is expelled, resulting in a bloody show. When cervical mucous is spread and dried on a slide, it is characterized by poor crystallization, or beading,
Decidua
The endometrial changes during pregnancy are known as the decidual reaction, and the altered endometrial lining is known as the decidua.
Internal os
The opening into the uterus
Chorion
The outer membrane that surrounds the embryo/fetus and becomes the fetal part of the placenta. One layer of the extraembryonic mesoderm is the extraembryonic somatic mesoderm. This layer will combine with the two layers of the trophoblast to form the chorion and the chorionic sac. Within the chorion, the embryo, amniotic sac, and umbilical vesicle are attached to the chorion by the connecting stalk that will become the umbilical cord. The chorion or outer membrane contains blood vessels that atrophy as pregnancy advances, but no nerves.
Syncytiotrophoblast
The outer synctial layer of the trophoblast that actively invades the uterine wall forming the outermost fetal component of the placenta. This is the site of transport with substances moving from the apical membrane (facing maternal blood in the IVS), across the cell wall and villous stoma to the basal membrane (facing the fetal capillary epithelium)
Describe maternal and fetal circulation of the placenta
The placenta is a unique vascular organ that receives blood supplies from both the maternal and the fetal systems and thus has two separate circulatory systems for blood: (1) the maternal-placental (uteroplacental) blood circulation, and (2) the fetal-placental (fetoplacental) blood circulation.
Discuss the concept of the placental "barrier"
The placenta is an imperfect barrier that allows many substances to cross from the maternal to the fetal circulation and from the fetal to the maternal circulation. The rate and amount of placental transfer depend on the permeability and the ability of various mechanisms to restrict movement
Cytotrophoblast
The point of contact between fetal and maternal tissue Forms into columns of cells that become the anchoring villi of the placenta Invade uterine spiral arteries, replace their endothelial layer, and begin the process of remodeling these arteries into low-pressure, high-volume, deinnervated open vessels needed to sustain the developing fetus; occurs in two waves First wave: takes place in the first weeks following implantation, as cytotrophoblast cells invade the spiral arteries in the decidua Second wave: between 12 - 20 weeks of gestation; during this period the cytotrophoblast extends into the myometrial portion of the spiral arteries, which accommodates changes in uterine blood blow **The genesis of pre-eclampsia is cytotrophoblast invasion, wherein the second wave does not occur and the maternal spiral arteries remain small, high-resistance vessel
Forepelvis
The portion of the pelvis (pelvic cavity) located anterior to a line defining the maximum transverse diameter of the superior pelvic aperture (inlet)
Hind pelvis
The portion of the pelvis (pelvic cavity) located posterior to a line defining the maximum transverse diameter of the superior pelvic aperture (inlet)
Explain the effect of pregnancy on protein metabolism
The products of conception, the uterus and maternal blood are relatively rich in protein rather than fat or carbohydrates
Pubic rami
The pubic rami comprising of both superior and inferior ramus is thin and flattened portion of ischium that is the lowermost portion of coxal bone. Prone to injury.
Lie
The relation of the long axis of the fetus to that of the mother; longitudinal or transverse
Pubic arch
The two inferior rami form the apex of the pubic arch, merging into a similar ramus on the ischium
Umbilical vein
The umbilical veins originate as a pair of vessels; however, the right vein and part of the left degenerate so that only a single vessel remains to return blood from the placenta to the fetus. As these vessels degenerate, the Ductus Veinosis develops in the liver and connects the remaining umbilical vein with the inferior vena cava. At birth the umbilical vein and the DV are obliterated with the cutting of the cord and the modifications in the circulation. The remnants of the vessels are the ligamentum teres and ligamentum venosum, respectively.
Describe the musculature changes of the uterine cavity during pregnancy
The uterine musculature during pregnancy is arranged in three strata. The first is an outer hoodlike layer which arches over the fundus and extends into the various ligaments. The middle layer is composed of a dense network of muscle fibers perforated in all directions by blood vessels. Last is an internal layer, with sphincter-like fibers around the fallopian tube orifices and internal cervical os. Most of the uterine wall is formed by the middle layer. Each cell in this layer has a double curve so that the interlacing of any two gives approximately the form of a figure eight. This arrangement is crucial because when the cells contract after delivery, they constrict penetrating blood vessels and thus act as ligatures. Early in pregnancy the walls of the corpus are thick, but they thin during the pregnancy. By term the myometrium is 1-2 cm thick with thin, soft, readily indentable walls through which the fetus can be palpated
Intervillous space
The uteroplacental circulation starts with the maternal blood flow into the intervillous space through decidual spiral arteries. Exchange of oxygen and nutrients take place as the maternal blood flows around terminal villi in the intervillous space. The in-flowing maternal arterial blood pushes deoxygenated blood into the endometrial and then uterine veins back to the maternal circulation. The fetal-placental circulation allows the umbilical arteries to carry deoxygenated and nutrient-depleted fetal blood from the fetus to the villous core fetal vessels.
Define/describe discomfort of pregnancy: Cloasma, linea nigra
This darkening is related to increased activity/number of melanocytes. Etiology is uncertain, but levels of melanocyte-stimulating hormone, a polypeptide similar to corticotropin are elevated throughout pregnancy. Estrogen and Progesterone are reported to have melanocyte-stimulating effects. Linea Nigra - The midline of the anterior abdominal wall skin (linea alba) takes on dark brown-black pigmentation. Chloasma - Also called the mask of pregnancy. Irregular brownish patches of varying size appear on the face and neck.
Describe the childbirth education method: Psychosexual method (Kitzinger)
This method stresses birth as a profound psychological and sexual experience for a woman. Method emphasizes relaxation that puts a woman more in tune with her body. Kitzinger suggests several breathing patterns for labor, each adjusted to the intensity and rhythm of the contractions. Two methods of relaxation were developed: touch and Stanislavsky technique of imagining the contrasting sensations of bodily tension and relaxation
Describe the childbirth education method: Natural Childbirth
To prevent the fear-tension-pain cycle Dick-Read developed a method of slow abdominal breathing in the early stage of labor and rapid chest breathing in the latter stage.
What is coiling of the umbilical cord
Too tightly coiled cords are associated with bad outcomes because blood flow is restricted. Almost no coiling and very little Wharton's jelly. Would be easy for cord to get pressed up against fetal head or shoulder and lead to a bad outcome, including stillbirth.
What is the etiology of Down syndrome
Trisomy 21, result of meiotic nondisjunction, which increases with maternal age Mental and physical disabilities of varying severity Associated with congenital heart defects, obstructions of the GI tract, and frequent respiratory infections Incidence is 1/700-1/1000 AMA (particularly women over age 35) is a risk factor for trisomy 21
Umbilical artery
Two carry deoxygenated blood away from the fetus, to placenta/ mother.
Name the four bones of the pelvis
Two innominate bones - - each has 3 parts: the pubis, the ischium and the ilium Sacrum Coccyx
Define/describe discomfort of pregnancy: Heart palpitations
Typically is due to the increase in blood volume and heart rate experienced during pregnancy. Palpitations are most commonly seen between 28 and 32 weeks gestation, when the heart stroke volume peaks. Sinus tachycardia is seen in the 3rd trimester due to the physiological increase in heart rate.
Sickle Cell Trait prenatal care
U/A every trimester due to increased risks for UTI
White blood cells and nitrates in a urinalysis may indicate...
UTI
When would you change a women's EDD determined by LMP?
Ultrasound measurement in the first trimester up to and including 13 6/7 weeks is the most accurate method to establish/confirm gestational age. Depending how early the first trimester U/S was performed: a discrepancy of more than 5 days based on an ultrasound before 9 0/7 weeks of gestation is an appropriate reason to change the EDD to correspond with the U/S dating. With the U/S was performed between 9 0/7 and 13 6/7 weeks, a discrepancy of more than 7 days supports changing the EDD to the ultrasound dating
Velamentous insertion of cord
Umbilical cord vessels run through the amnion and chorion before entering the placenta, leaving the vessels unprotected. This type of insertion may lead to rupture and fetal hemorrhage, particularly if associated with vasa previa (transcervical position). This finding is more common in twin placenta.
Luteal Phase
Under LH influence the follicles granolas cells that are left in the ruptured follicle become enlarged and undergo luteinization and form the corpus luteum.
Define/describe discomfort of pregnancy: Urinary Frequency and Urgency
Urinary frequency, defined as urinating more than seven times during the daytime hours, as a non pathologic discomfort of pregnancy occurs at two different times during the prenatal period. Frequency during the first trimester is due to hormonal changes affecting levels of renal function as well as developing hypervolemia. Urinary frequency during the third trimester occurs most often in primiparous women, after engagement has occurred when the presenting part descends into the pelvis and causes direct pressure against the bladder.
Define/describe discomfort of pregnancy: Dyspareunia
Vulvovaginal pain during sexual activity may stem from a number of causes during pregnancy. Physiologic changes such as pelvic/vaginal congestion may play a role. Vaginal sensitivity may cause dyspareunia, and vascular engorgement may contribute to vulvar varicosities that can also cause pain or discomfort. A woman who reports dyspareunia while pregnant may have a previous experience of sexual dysfunction or IPV that she is reporting for the first time during pregnancy.
Hematologic changes in WBCs with pregnancy
WBC count increases during pregnancy, ranging from 5000 to 15,000 per cubic millimeter. Most of the increase is in the numbers of neutrophils, which act as the first WBC responders in the body's reaction to an infectious or inflammatory process. The WBC count may rise as high as 30,000 per cubic millimeter during labor and birth without infection
Describe placental tranfer between mother and fetus
Water diffuses and electrolytes follow (Fe, Ca); Glucose is the fetus' main source of energy and passes the placenta via simplified transport. The fetal blood sugar concentration is 2/3 of the mother's and depends on it; proteins are too big to pass through, but Peptides and amino acids, though, pass through the placental barrier via active transport and thus insure the fetus' own protein synthesis.
Discuss impacts on sexuality during: Young Adulthood
Women achieve maturity in sexual role and in the relationship tasks started in adolescence (developing intimacy, developing long-term commitment) Important career and personal decisions, increasing responsibility Balancing relationships, career, and children is big concern Sexual activity usually decreases during these years.
What are the current recommendations for HPV testing
Women aged 30-65 years or Presence of abnormal glandular cells (AGC) on a pap sample requires a follow-up colposcopy, HPV DNA testing and endometrial sampling Other abnormal pap results may require reflex to HPV
Discuss impacts on sexuality during: Menopause
Women continue to be sexual and enjoy sexual activities - - 3 main concerns: decreased sexual desire, vaginal lubrication and ability to have an orgasm. Critical issue with women is availability of a partner
Discuss impacts on sexuality during Postpartum
Women frequently report lessened sexual desire and decreased sexual activity Sleep loss, exhaustion, physical discomforts (dyspareunia) are all common during this period After discharge has subsided, a vaginal dryness may occur w/ decreased levels of estrogen and progesterone (most common among women who are breastfeeding) - - offer lubrication
Discuss HIV testing and counseling in pregnant women
Women should be screened for HIV early in pregnancy and, ideally, again in the third trimester. screening tools detect antibodies to HIV, not the presence of the virus itself. Antibodies appear 2-12 weeks after infection occurs. Routine screening can be performed with in-office test kits using oral fluids, blood, or serum with laboratory testing on blood. In-office rapid testing allows provision of results in 20 mins. The most commonly used laboratory screening test is a conventional/rapid enzyme immunoassay (EIA), or rarely, a chemiluminescent immunoassay (CIA). HIV + = increased prenatal care; scheduled c-section; neonates = antiretroviral therapy
Health implications and differences in screening, diagnosis and tx for STIs for women with same-sex partners
Women who have sex with women (WSW) - recent studies show that some WSW, particularly adolescents and and young women as well as women with both male and female partners, might be at increased risk for STDs and HIV based on reported risk behaviors WSW at risk for HPV - routine cervical cancer screening should be offered to all women, regardless of sexual orientation or sexual practices BV is common in WSW, however, routine screening for BV in asymptomatic women not recommended
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Gonorrhea
Women with gonorrhea are also frequently coinfected with chlamydia, so all CDC approved treatments for gonorrhea include treatment for chlamydia; this strategy is intended both to reduce the incidence of PID and to combat increasing antibiotic resistance. Thus women with gonorrhea should be treated zithromax or doxycycline in addition to a cephalosporin, even if they test negative chlamydia. Transmission of gonorrhea occurs through oral, anal, and vaginal sex and contact with secretions from the urogenital tract. Vertical infection is possible resulting in ocular infections in neonates. Otherwise healthy nonpregnant adults do not need a TOC if treated with Rocephin and Zithromax. If treatment with Rocephin was not possible, the woman will need a TOC with a culture, 1 week after finishing treatment.
Amnion
a membrane that when first formed, closely covers the embryo. It fills with the amniotic fluid which causes the amnion to expand and become the amniotic sac which serves to provide a protective environment for the developing embryo.
uterus
a muscular pear shaped, hollow thick walled organ that opens into the vagina at the cervix then widens toward the top where the uterine tubes enter *composed of fundus, body and cervix
grand multipara
a woman who has given birth 5 or more times
Primipara
a woman who has given birth to only one child
Multipara
a woman who has had two or more children
nulligravida
a woman who has never been pregnant
Nullipara
a woman who has never given birth before
primigravida
a woman who is pregnant for the first time
Multigravida
a woman who is pregnant for the second or more times
Discuss impacts on sexuality during: Adolescence
age 12-19- adolescent sexual activity is largely discouraged by policy makers, but adolescents assign meaning, importance and positivity to first intercourse. Peer pressure to engage in SA common SA is common, normal, but often uninformed, counseling re: personal safety, STI prevention, contraception, and expectations should begin at age 12
Vestibular bulbs
aggregations of erectile tissue that are an internal part of the clitoris
Ethnic population screening (population, timing, meaning and appropriate follow-up) for Fragile X
all ethnic backgrounds and racial groups; women of all ages can have a child affected with fragile X syndrome, whether or not they have had previous healthy children; in the general population, women, and not men, are usually offered carrier testing. X-linked diseases are inherited through the mother. If the test determines that the mother is a carrier, prenatal testing (chorionic villi sampling [CVS] or amniocentesis) during pregnancy can be done to see whether or not the baby has inherited the disease
cardinal ligament
also called the transverse cervical ligament or mackenrodt ligament; is the thick base of the broad ligament
Presumptive signs of pregnancy
ammenorrhea, n/v, tingling, tenderness, increased modularity and/or enlargement of breasts, increased urinary frequency, fatigue
HEP B
antibody screen; if positive mother plan to vaccinate newborn and give immunoglobulin within 12 hours of birth if mother has positive antigen; breast feeding is not contraindicated if newborn is vaccinated
Identify the volume of amniotic fluid throughout pregnancy
approx 7ml of amniotic fluid by 8 weeks 30 ml by 10 weeks 190 ml by 16 weeks average of 700- 800 ml by term with wide variations decreasing to about 400 ml at 42 weeks
Transformation zone
area where the endocervix and exocervix meet; metaplastic cells are found here, it is the region where most cervical cancers orginate
iliococcygeus
arises from a facial line on the obturator internus muscle along the pelvic wall of the obturator foramen and extends to insert on the lateral margins of the coccyx and anococcygeal
Pale Placenta
associated with immature neonates and anemia
Cloudy membranes of placenta
associated with infection
Foul odor of placenta
associated with infection
Thin cord variation
associated with oligohydramnios and poor fetal growth
Nodules of plaques of the fetal surface of placenta
associated with oligohydramnios and renal agenesis, squamous metaplasia, and infection
Thick cord variation
associated with polyhydramnios and macrosomia
Green stained placenta
associated with presence of meconium
Full integrated Genetic Screening
at 11-13 week and 15-22 weeks: ultrasound and evaluation of the NT and serum screen
Cardinal ligaments
attach upper vagina, cervix and uterus to the side walls of the pelvis
Uterosacral ligaments
attach upper vagina, upper portion of cervix and uterus to the 3rd sacral vertebra
Broad ligament
attach uterus to medial aspect of the ilium
Round ligament
attach uterus to mons pubis
sacrospinous ligament
help provide stability to the pelvis in part by supporting the sacrum and restricting its ability to tilt; triangular with a broad base that attaches to the lateral margins of the sacrum and coccyx and insertion at the apex of the ischial spine
puborectalis
intermediate fibers that form a U loop around the anal rectal junction and insert into the posterior wall of the rectum, blending with the anal spincter
Chadwick sign
bluish color of the vulva, vagina and cervix; 6-8 weeks
iliopectineal line
border of iliopubic eminence, arcuate line from ilium and pectineal line from pubis; makes up linea terminalis with sacral promontory
When is the fertilized egg referred to as the embryo?
beginning of week 3 after ovulation and fertilization
Oral Estrogen SE
bloating, nausea, increased breast size, leucorrhea, cervical ecotype, HTN, increased GB cholesterol, Telangestasia, hepatocellular adenomas, stroke, MI, VTE
QuantiFERON - TB GOLD
blood test alternative to PPD Perferred for BCG patients Greater specificity (fewer false positives)
Hematologic changes in blood volume with pregnancy
blood volume increases by 30% to 50%; the more rapid increase in plasma volume causes hemodiluation. This hemodilution lowers the hemoglobin, hematocrit and RBC count per milliliter
pelvic inlet
bounded posteiorly by the promotor and alae of the sacrum, lateraly by the linea terminalis and anteriorly by the horizontal pubic rami and the symphysis pubis
arterial blood supply of the clitoris
branches of the internal pudendal artery *deep arteries of the clitoris supply the corpus cavernosum *artery of the bulb supplies the bulb of vestibule *dorsal artery of the clitoris runs on the dorsum of the clitoris
Probably signs of pregnancy
breast changes (colostrum expression); skin changes, enlarged abdomen, enlarged uterus, hagars sign, goddels sign, chadwicks sign
Trophoblast
cells forming the outer layer of a blastocyst, which provide nutrients to the embryo and develop into a large part of the placenta. If trophoblast invasion is too extensive, placenta accreta can result; if invasion is too little the risk of miscarriage or placental abruption is increased. By the seventh day after fertilization, the trophoblast begins to differentiate into two layers: the inner cytotrophoblast and the outer syncytiotrophoblast layer.
Define/describe discomfort of pregnancy: Nausea and vomiting
common problem in prenatal period occurring in up to 80% of pregnant women; presumptive sign of pregnancy; peak prevalence is at 11 weeks gestation with average time of onset between 5 and 6 weeks for most women, resolves by 14 to 16 weeks gestation; nausea is more apt to be present when stomach is empty, which may be why it is more noticeable in the morning; cause, unknown, but likely due to interplay of hormonal changes of pregnancy (hcg, estrogen, progesterone, placental prostaglandin E2), slowed peristalsis, and genetic factors
Describe the stage of fetal development in terms of fetal size, physical appearance and significant milestones at: 28 weeks
crown-rump length is approx 25cm, fetus weighs about 1100g (a large eggplant); skin is covered with vernix caseosa, isolated eye blinking peaks at 28 wks, eye lashes present; neonate born at this age has a 90% chance of survival without physical or neurological impairment
cervix
cylindrical, fibromuscular lower portion of the uterus that is sometimes referred to as the neck of the uterus; composed of dense collagenous connective tissue
What are some common autosomal recessive disorders?
cystic fibrosis, sickle cell anemia, and Tay Sachs disease Beta and Alpha Thalassemia
During what period are most pregnancy tests able to measure human chorionic gonadotropin (hCG)?
embryonic period - - about 4 weeks
internal os
endocervix; internal part of the cervix that opens into the uterus; usually firmly closed in non-pregnant and slightly open in women who have given birth
external os
exocervix; external part of the cervix that opens into the vagina
Sacrosciatic notch
deep indentation in the posterior border of the hip boneat the point of untion of the ilium and ischium
High hemoglobin can indicate
dehydration, burns and diarrhea
High RBCs
dehydration, diarrhea and burns
Hcg in normal pregnancy
detectable first day after implantation; 8-9 days after ovulation; 8-11 days after conception; doubles every 2 days; peaks at 8.5 to 10 weeks; serial levels are of value but individual numbers tell us nothing
Wet Prep
diagnosis and treatment in symptoms patient with BV Prevent pre term labor
Trepanema test
diagnostic syphilis test; done when positive RPR (go to trepanned test because often have false positive RPRs)
What are STI prevention methods
discuss the fact that the infection is sexually transmitted and address whether it is possible for the infection to be transmitted in other ways, such as through common contact; condoms prevent - not lambskin
venous blood supply of the clitoris
dorsal veins drain into the internal pudendal veins
Hematologic changes in clotting factors with pregnancy
during pregnancy, factors that promote hemostatsis and fibrinolysis are enhanced. Changes occur to help control bleeding when there is an increased risk for hemorrhage with implantation and placental development, and again during the 3rd stage of labor when the placenta detaches. During pregnancy, fibrinogen doubles and clotting factors VII, VIII, IX, and X and the von Willebrand factor all increase. Prothrombin and factor V do not change and factor XI actually declines slightly.
Describe the connective tissues changes of the cervix and vagina
early as 1 month after conception the cervix begins to undergo pronounced softening and cyanosis. These changes result from increased vascularity and edema of the entire cervix, together with hypertrophy and hyperplasia of the cervical glands. The majority of the cervix is connective tissue. Rearrangement of this collagen-rich connective tissue is necessary to permit functions as diverse as maintenance of a pregnancy to term, dilation to aid delivery, and repair following parturition so that a successful pregnancy can be repeats The cervical ripening process involves connective tissue remodeling that decreases collagen and proteoglycan concentrations and increases water content compared with the nonpregnant cervix
What hormone(s) do ovaries release?
estrogen and progesterone
Preconception Care
every woman, every time -preg testing, family planning visits -primary care -visits for chronic disease -work physicals -prenatal care/ postpartum care -health fairs
Adnexae
fallopian tubes and ovaries
S/S anemia at initial visit
fatigue, weakness, headache, dizziness, exercise intolerance, shortness of breath, PICA
Uterus
female reproductive organ located between the bladder and the rectum, in the pelvic area
Describe the stage of fetal development in terms of fetal size, physical appearance and significant milestones at: 16 weeks
fetal crown rump length is 12cm (avocado) and weight is 110g; eye movements begin at 16 - 18 weeks, coinciding with midbrain maturation; teeth begin to form
Describe the stage of fetal development in terms of fetal size, physical appearance and significant milestones at: 32 weeks
fetal weight 2100g, crown-rump length is approx 28cm; toenails present, body is filling out; testes descending; fetus will gain 1/3 to half birth weight in next 7 weeks.
Describe the stage of fetal development in terms of fetal size, physical appearance and significant milestones at: 40 weeks
fetal weight 3400g, fetal crown rump is about 36cm; prominent chest, breasts protrude, fingernails beyond fingertips, testes in scrotum or palpable in inguinal canals
Describe the stage of fetal development in terms of fetal size, physical appearance and significant milestones at: 36 weeks
fetal weight is approx 2900g, crown-rump length averages 32cm; losing most of the fine lanugo covering the body along with the vernix
Describe the stage of fetal development in terms of fetal size, physical appearance and significant milestones at: 24 weeks
fetus weighs approx 630g (ear of corn), skin is wrinkled, red and fat deposition begins; eyebrows and eyelashes are usually recognizable; lung development is nearly complete - viability is achieved
Describe the stage of fetal development in terms of fetal size, physical appearance and significant milestones at: 20 weeks
fetus weighs more than 300g (a banana), fetal crown-rump length is 19cm; myelination of spinal cord begins; fetal skin has become less transparent, downy lanugo covers its entire body and vernix protect the body; fetus can swallow now and digestive system is producing meconium
Vagina
fibromuscular tubular sex organ that is part of the female genital tract
Initial Hormonal changes of menopause
first hormonal change is gradual decline in levels of progesterone --> relative excess of estrogen --> irritability, anxiety, breast tenderness, sleep disturbance, decreased libido
anal sphincter
flat plan of muscle fibers in elliptical shape that adheres to skin surrounding margin of anus; always in a state of tonic ctx, keeps anal canal closed in absence of antagonistic muscle activity
Platypelloid Pelvis
flat, short AP diameter and a wide transverse diameter
How is a blastocyst formed?
fluid accumulates in the morula which forms the blastocyst; this is the 3rd stage in conceptus development
Fetal hydrops
fluid accumulation in 2+ compartments: pleural effusion, ascites, pericardial effusion -not compatible with life
Prepuce
fold of skin covering clitoris
labia majora
folds of connective and adipose tissue that extend inferiorly from the mons and merge posteriorly into the perineal body to form the posterior commissure
What are polygenic/multifactoral disorders?
for each, normal parents have recurrence risks of 1%-5% after one affected child, after 2 affected offspring, the risk is higher. Approximately 1% of neonates are abnormal but have an apparently normal chromosomal complement and have not undergone mutation at a single genetic locus.
pubic arch
formed by convergence of inferior rami of ischium and pubis on either side, below pubic symphysis
Gynecoid Pelvis
frequently seen in women
Gynecoid Pelvis
frequently seen in women; 41-42% Outcome: ideal shape for childbearing Inlet: rounded Sacrum: parallel with the symphysis pubis Sacrosciatic notch: rounded with 2.5-3 fingerbreadths Ischial spines: blunt and neither prominent nor enroaching Pubic arch: wide arch (<90 degrees)
Sacrospinous ligament
from ischial spine to lateral margins of the sacrum
Sacrotuberous ligament
from sacrum to tuberosity of the ischium
sacrococcygeal joints: synovial
hinge joint that allows flexion and extension of coccyx
high GDM group that must be testing early
history of gum, unexplained UFD, congenital anomalies or polyhydramnios, macrocosmic infant, obesity (BMI >30), first degree relative with DM or glycosuria
Clitoris
human female's most sensitive erogenous zone and generally the primary anatomical source of human female sexual pleasure
What are common malformations caused from polygenic/multifactoral disorders
hydrocephaly, anencephaly, and spina bifida (neural tube defects); facial clefts (cleft lip and palate); cardiac defects; pyloric stenosis; omphalocele; hip dislocation; uterine fusion defects and club foot (talipes equinovarus). Also conditions include: cardiac anomalies (most types); renal agenesis (unilateral or bilateral); ureteral anomalies; hypospadias
anterior portion of the vulva is supplied from _____ nerve and the genital branch of the _____ nerve.
ilioninguinal and genitofemoral
5 bones of the pelvis
ilium, pubis, ischium, sacrum/coccyx
False Pelvis
includes the iliac fossa and iliac crest, receives its name because it has little obstetric significance yet defines the lower border of the abdominal cavity
False Pelvis
includes the iliac fossa and iliac crest, receives its name because it has little obstetric significance yet defines the lower border of the abdominal cavity *function is support the enlarged uterus during pregnancy
Missing cotyledon
incomplete expulsion of placenta - associated with uterine atony and PP infection
Infarctions of placenta
localized area of ischemic tissue necrosis when there is an obstruction of the villus blood supply - most common at periphery of placenta, small infarctions are normal variations but large infarctions are associated with HTN, stillbirth, placental abruption, and fetal growth restriction
Pregnancy over 35
increased risk: -chronic illness & pregnancy complications (GDM, stillbirth, placental problems) -infertility 20% -chromosomal anomalies *early prenatal care for early genetic screens
venous blood supply of the uterus
internal iliac veins
arterial blood supply of the perineum
internal pudendal artery
Mons veneris
is a rounded mass of fatty tissue found over the pubic symphysis of the pubic bones
Rectovaginal septum
is a thin structure separating the vagina and the rectum
Position
is the fetal presenting part to the right or left side of the birth canal?
adductor magnus
large triangular muscle, situated on the medial side of the thigh that adducts the leg at the hip also responsible for the lateral and internal rotation of the upper leg
Follicular phase
lasts from 1 to day 14 of the ovarian cycle; LH surge at end of cycle that causes ovulation
Hymen
membrane that surrounds or partially covers the external vaginal opening
pubococcygeus proper
lateral fibers go directly back to form a Y and insert on the lateral margins of the coccyx
Mons pubis
layer of fatty tissue that overlays the pubic bones
short cord variation
less than 32 cm, associated with disorders that limit fetal movement, such as Down syndrome, neuromuscular disorders, and fetal limb dysfunction. Also associated with FHR abnormalities in labor as a result of traction on the cord w/ fetal descent
colles fascia
membranous layer of perineal fascia
Cervix
lower part of the uterus in the human female reproductive system
isthmus
lower segment of the uterus
High MCV
macrocytic anemia; B12 or folate deficiency
levator ani
made up of the puborectalis, pubococcygeus, iliococcygeus, coccygeus muscle and associated fascia *muscle around the vagina, urethra and rectum allow passage of these openings and contribute to the fecal and urinary continence
False Positive PPD can occur if...
person is infected with myobacteria that isn't TB, previous BCG vaccine, incorrect TB admin, interpretation of reaction is incorrect
Bartholin's Gland
major or greater vestibular glands are located beneath the fascia of the vestibule on either side of the vaginal opening at 4 and 8 o'clock
bartholins glands
major or greater vestibular glands are located beneath the fascia of the vestibule on either side of the vaginal opening at 4 and 8 o'clock
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Hepatitis C
majority of infections is asymptomatic, but occasionally can present with fatigue, anorexia, nausea, vomiting, headache, fever, dark urine, jaundice, and moderate liver enlargement with tenderness; HCV screening is recommended by CDC and USPSTF for all persons born during 1945-1965 and others based on their risk for infection or on a recognized exposure, including past or current injection drug use, receiving a blood transfusion before 1992, long-term hemodialysis, being born to a mother with HCV infection, intranasal drug use, receipt of an unregulated tattoo, and other percutaneous exposures; therapy is supportive Routine screening for HCV infection is not recommended for all pregnant women - only same screening for increased exposure
Describe the phases and physiology of the sexual response in females
many women do not capitalize on their right to enjoyable sex, girls are socialized to protect and preserve their sexuality while boys learn that they have the right to pleasurable sex
ischial tuberosities
marks lateral boundary of pelvic outlet
midpelvis
measured at the level of the ischial spines plane of least dimensions
Low MCV
microcytic anemia; Iron deficiency or thalassemia
venous blood supply of the anus
middle and inferior rectal vein
Define/describe discomfort of pregnancy: Varicosities and spider nevi
more apt to occur in women with familial tendency or congenital predisposition result from increased blood volume, impaired venous circulation, and increased venous pressure in the lower extremities caused by pressure on the enlarging uterus on the pelvic veins when the woman is sitting or standing and by pressure on the inferior vena cava when she is supine; rest and use of compression stockings that are put on after elevating the legs before arising in the morning
long cord variation
more than 75 cm, associated with knots and fetal enlargement, as well as increased amniotic fluid and fetal activity
Anthropoid Pelvis
most common in non-white races, Outcome: favors posterior position of fetus; adequate for vaginal birth Inlet: oval Sacrum: posteriorly inclined Sacrosciatic notch: aveage height but very wide; 4 fingerbreadths Ischial spines: usually prominent; transverse diameter is less than gynecoid put not as much as android Pubic arch: somewhat narrow
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Epididymitis
most commonly, chlamydia trachomatis, neisseria gonorrhea, trauma to the genital area, coinfection with UTI A swollen red or warm scrotum, one sided testicular pain and tenderness, dysuria, urinary hesitancy, Penile discharge, painful intercourse/ejaculation, testicular lump, inguinal lymph node enlargement, lower abdominal and pelvic pain, blood in the semen, fever. tx: antibiotics for infecting organism; doxycycline 100mg PO q 12h x7 days
Define/describe discomfort of pregnancy: Supine hypotensive syndrome
most frequently in the 3rd trimester though can also occur in the 2nd trimester. Also known as Vena Cava Syndrome. When pregnant woman is in supine position, the gravid uterus can compress the inferior vena cava causing decreased blood pressure. Symptoms: dizziness, tachycardia, pallor, nausea, sweating. Changing position to the side quickly results in alleviation of symptoms
semimembranosus muscle
most medial of the three hamstring muscles in the back of the thigh; helps to extend the hip joint and bend the knee joint
Android Pelvis
mostly seen in men Outcome: heavy pelvis, difficult vaginal birth, increases incidence of posterior position and forceps-assisted delivery, c-seciton Inlet: heart shaped, limited space in the posterior portion for accommodating fetal head Sacrum: anteriorly inclined and flat Sacrosciatic notch: highly arched and narrow, 1.5-2 fingerbreadths Ischial spines: prominent and frequently encroaching; decrease the transverse diameter of the midplane Pubic arch: narrow, acute angle much less than 90 deg
Android Pelvis
mostly seen in men, heart shaped, anterior segment is narrow and triangular
Endometrium
mucosal lining of the uterine cavity composed of ciliated columnar epithelium glands that secrete a thin alkaline mucus and mesenchymal stroma
semitendinosus
muscle located in the back of the thigh; function is similar to semimembranosus muscle
biceps femoris
muscle of the posterior thigh that extends the hind limb when propelling, rearing or kicking
internal anal sphincter
muscular ring that surrounds 2.5-4cm of anal canal, involuntary
Where does fertilization take place?
near the end of the fallopian tube aka the ampulla
Isthmus
nferior-posterior part of uterus
HSV
no intercourse/oral genital contact in 3rd trimester; may consider suppression to reduce transmission; serum screening not routinely done because not cost effective
Anthropoid Pelvis
occurs occasional in women, AP diameter is much larger than the transverse diameter
What are considerations for LGBTQ patients at the provider level?
often face a combination of ignorance and discrimination in accessing health care. While homophobia and transphobia among healthcare providers is declining, it is still very much in existence. LGBT persons will be less likely to re-access care if experience is bad.
External os
opening into the vagina
urethral meatus
opening to uterthra
What is another term or name for the embryonic period?
organogenesis
ovaries
organs of gamete production in the female; manufacture estrogen and progesterone (part of endocrine system)
pubovaginalis
origin in the posterior aspect of the pubis and insertion is the fascia of the vagina and perineal body; the muscle is in a U shape around the vagina
Round ligament
originates below and anterior to the origin of the fallopian tubes
uterosacral ligament
originates with a posterolateral attachment to the supravaginal portion of the cervix and inserts into the fascia over the sacrum
Hematologic changes in Plasma with pregnancy
plasma volume beings to increase as early as 6-8 weeks gestation; by 32 weeks gestation, plasma volume will have increased 45-50% higher than nonpregnant levels. This increase helps to meet increased maternal metabolic needs, to circulate blood within the dilated uterine vascular system, to provide nutrients to the growing fetus, and to protect the mother against the consequences of blood loss during labor and birth
ischial spines
pointed triangular eminence that exends backward from the posterior body of the ischium, landmakr for fetal engagement/station
Sacrum
triangular bone with the base superiorly and apex inferiorly: 5 vertebrae are fused, the first sacral vertebrae articulates with lower surface of the fifth lumbar vertebra.
arterial blood supply of the ovaries
ovarian artery
Ovarian ligaments
ovary to the lateral surface of the uterus
What hormone(s) does the Posterior Pituitary release?
oxytocin
The clitoris and the vestibule receive _____ innervation from the _____ nerves derived from the uterovaginal plexus.
parasympathetic; cavernous
linea terminalis
part of pelvic brim, which is part of pelvic inlet consists of pectineal line, arcuate line, pubic crest, sacral promontory and sacral ala
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Trichomoniasis
pear shaped protozoa have five flagella and highly motile. They are transmitted through sexual contact, which transfers infected secretions to the urethra and vagina. Trich is often asymptomatic; Symptoms include vaginal itching, irritation, and malodorous vaginal discharge. ABdominal discomfort may also be present. Common exam findings include an inflamed and irritate vulva with minor excoriations, and possibly a frother, thin, yellow green vaginal discharge. The vagina and cervix may be a deep red or pink, known as strawberry cervix; Treatment for nonpregnant women is Flagyl 2 gram orally once or Tindamax 2 gram orally once. For pregnant women, Flagyl 2 gram orally once. Counseling includes no alcohol for 24 hours after treatment with flagyl and 72 hours after treatment with tindamax. Current sexual partners should be treated, even if they are asymptomatic.
Amniocentesis
performed in most centers at 15-16 seeks (range 15-20), because at this time amniotic fluid volume has reached 150-250 ml, the uterus has reached the pelvic brim, adequate fetal cells are available, and diagnostic studies can be completed in time for a second trimester abortion. The overall incidence of miscarriage is 1-1.7%; the risk is higher with advanced maternal age.
ovarian ligament
peritoneum that extends beneath the fimbriated end of the fallopian tube toward the pelvic wall forms the indofundibulopelvic ligament or suspensory ligament of the ovary
forepelvis
portion of pelvis located anterior to a line defining the maximum transverse diameter of the pelvic inlet has larger capacity than hindpelvis and varies less in shape
hind pelvis
portion of the pelvis located posterior to a line defining the maximum transverse diameter of the pelvic inlet - has smaller capacity than forepelvis and is more variable in shape r/t prominence of sacral vertebrae
Attitude
posture of the baby; relationship of fetal parts to one another
Presentation
presenting part is that portion of the fetal body that is either foremost within the birth canal or in closest proximity
Incomplete membranes of placenta
remnants of membranes are usually spontaneously expelled after the birth; however, they can cause subinvolution of the uterus, uterine atony, or infection if retained
labia minora
two thin folds of connective tissue
pubococcygeus
primary portion of the levator ani; originates at posterior border of the symphysis pubis and sweeps back to insert on lateral margins of the coccyx; divided into 3 bands
clitoris
prinicipal female erogenous organ and is the erectile homologue of the penis; rarely exceeds 2 cm in length and is composed of a glans, a body and two crura
Regulation of hormones in menopause
progesterone down regulates estrogen receptors --> makes estrogen less effective --> hot flashes, vaginal dryness, cessation of menses
broad ligament
two winglike structures that extend from the lateral uterine margins to the pelvic sidewalls
Identify the purpose of amniotic fluid throughout pregnancy
provides space for symmetric fetal growth, maintains constant temperature and pressure, protects and cushions the fetus, allows free movement of the fetus and distributes pressure from uterine ctx evenly over the fetus; antibacterial helps to protect fetus from infection
Escutcheon
pubic hair - usually triangular pattern but may extend up toward umbilicus in women with higher levels of androgens
posterior portion of the vulva is supplied by the ____ nerve and by the _____ nerve of the thigh.
pudendal and posterior cutaneous
Hemoglobin A1C
reflects mean glucose over the 120 day life span of red blood cells- correlates with mean blood glucose over previous 8-12 weeks, >6.5 suggests TII DM, used in management of GDM to assess glycemic control,
FSH
released by the anterior pituitary, targets the ovaries where it stimulates the growth and development of the primary follicles and results in the release of estrogen and progesterone
LH
released by the anterior pituitary; LH targets the developing follicle with the ovary and causes ovulation, corpus lute formation and hormone production in the ovaries
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Bacterial Vaginitis
represents a disturbance in the vaginal microflora characterized by diminished or absent lactobacillus; evident as a thin white/gray homogeneous discharge, irritated vaginal mucosa, and introitus, possible cervicitis; Clue cells on microscopy, pH > 4.5, whiff test In nonpregnant women, Flagyl 500 mg orally 2X per day for 7 days, or MetroGel 0.75% one applicator per vagina at bedtime for 5 days or cleocin cream 2%, pervagina for 7 days. For pregnant women: Flagyl 500 mg orally 2X per day or Flagyl 250 mg orally 3X per day or cleocin 300 mg orally for 7 days
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Scabies
scabies mite burrows under the skin,. Persistent itching may result from reinfestation, allergic dermatitis, or secondary skin infection. Tx: Permethrin cream 5%. Apply to all areas of the body from the neck down. Wash off after 8-14 hours. Ivermectin: 200 mg/kg PO, repeat in 2 weeks. Lindane 1%: Apply a thin layer to the body from neck down. Wash off after 8 hours. Can cause a severe neurotoxic reaction. Do not use immediately after shower or bath. Do not use in persons with extensive dermatitis, or pregnant lactating women, or in children <2 years. Malathion is a pregnancy cat B Ivermectin cannot be used in pregnancy.
Varicella
screen by history; avoid exposure if not vaccinated and get vaccinated PP (1st dose and hospital 2nd dose at 6-8 week visit); do not get vaccination within 30 days of vaccine
Where does the external female genitalia receive nervous supply from?
sensory and parasympathetic
Sequential Screening for Aneuploidy
sequential screen calculates risk based on first trimester screening tests and returns the results to the woman before proceeding with further screening tests
2nd trimester labs
serum screening for genetic disorders, invasive testing for genetic disorders, anatomy sonogram
sacrotuberus ligament
situated at the lower and back part of the pelvis *it's function is to anchor the sacrum to the hip bones to prevent tilting
Fourchette
small band or fold of mucous membrane forming the posterior margin of the vulva and connecting the posterior ends of the labia majora
Lacunae
small spaces or "lakes" within the syncytiotrophoblast. Maternal blood occupies this space and fetal villi project into it.
sacral hollow
smooth concave anterior surface of the sacrum
Hegar sign
softening of the uterine isthmus; 6-12 weeks
arterial blood supply of the anus
superior and inferior rectal artery
RPR/VDRL
syphilis screening; done in first and possibly 3rd trimester; readily crosses the placenta; often false positives; when negative almost always correct; if have positive result go to FTA antibody testing
Gonorrhea and Chlamydia testing
test all high risk pts in 1st trimester (new partner, >1 partner, age <25, h/o stis, test again in 3rd trimester is positive in 1st or high risk; follow up positive test with test of cure
What are ethical considerations in the area of genetic counseling and prenatal diagnosis
testing for disorders that have no cure, eugenics, termination based on genetic testing, cost effectiveness of testing versus the possibility of improvement based on results, false positive results and the need for increased testing and parental distress
Fetal Fibronectin
testing for preterm labor; tests for the protein that is released into the secretions when connection between the uterine lining and amniotic sac is disrupted; many false positives
Organism, symptom, findings, screening recommendations, diagnosing, CDC tx recommendations, considerations for pregnancy, follow-up?, sequelae, prevention: Chlamydia
the CDC recommends screening all women with a new sexual partner and annual screening for women 25 years and younger. When left untreated, chlamydia can ascend into the upper reproductive tract and cause PID. Nucleic acid amplification test is the most common diagnostic test for chlamydia; it can be performed on urine, cervical, or liquid cytology specimens. Treatment for non pregnant women is: Zithromax 1 gram once. Erythromycin 500mg fours day for 7 days, Doxycycline 100mg, twice daily for 7 days. For pregnant Zithromax 1 gram X once, or Amoxicillin 500 mg orally 3X a day for 7 days. Breastfeeding: Zithromax is compatible with b/f. Single dose treatment is preferable. Ensure treatment of all sexual partners from the last 60 days. Retest pregos no sooner than 3 weeks, then 3 mths
Cotyledon
the cotyledons are the approximately 15-25 separations of the decidua basalis of the placenta, separated by placental septa. Each cotyledon consists of a main stem of a chorionic villus as well as its branches and subbranches etc. The cotyledons receive fetal blood from chorionic vessels, which branch off cotyledon vessels into the cotyledons, which, in turn, branch into capillaries. The cotyledons are surrounded by maternal blood, which can exchange oxygen and nutrients with the fetal blood in the capillaries.
Denominator
the denominator for a vertex presentation is the occiput; for a breech presentation is the sacrum
pelvic outlet
the lowest part of the pelvis; two imaginary triangles The top triangle from tuberosities to symphysis; the bottom triangle extends from the coccyx to the tuberosities
Embryogenesis is started by the process of cleavage, what is this?
the replication process; splitting into more cells without adding additional genetic material. This is completed about 30 hrs after fertilization
Nuchal translucency scan
the sonographic appearance of a subcutaneous collection of fluid behind the fetal neck. The measurement of fetal NT thickness at the 11-14-week scan has been combined with maternal age to provide an effective method of screening for trisomy 21
Vaginal fornices
the spaces created between the cervix and the ends of the vaginal walls - there are four fornices: anterior, posterior and 2 lateral
pubi rami
thin, flattened part of ischium superior and inferior rami form obturator foramen which acts as passage for blood vessels and nerves
venous blood supply of the fallopian tubes
through pampiniform plexus into ovarian veins
venous blood supply of the ovaries
through pampiniform plexus into ovarian veins; lt renal vein inferior vena cava
Fundus
top of uterus
Describe the stage of fetal development in terms of fetal size, physical appearance and significant milestones at: 12 weeks
usually palpable above the symphysis pubic, and fetal crown-rump length is 6-7cm (a lime); fingers and toes have become differentiated, skin and nails have developed, with rudiments of hair appearing, external genitalia are beginning to show definitive signs of male or female gender; spontaneous movements begin
arterial blood supply of the fallopian tubes
uterine & ovarian arteries
arterial blood supply of the cervix
uterine artery
arterial blood supply of the vagina
uterine artery and vaginal artery (proximal) internal iliac artery middle rectal artery (posterior vaginal wall) internal pudendal artery (distal walls)
arterial blood supply of the uterus
uterine, ovarian and vaginal arteries
Vaginal fornices
vault like structure of the vagina
venous blood supply of the vagina
veins drain into the internal iliac vein and the internal pudendal vein
venous blood supply of the cervix
venous drainage is via a plexus in the broad ligament that drains into the uterine veins
venous blood supply of the perineum
vesical venous plexus
Chorionic villi
villi that sprout from the chorion to provide maximum contact area with maternal blood. They are an essential element in pregnancy and are, by definition, a product of conception. Branches of the umbilical arteries carry embryonic blood to the villi. These villi are the main functional units of the placenta within which fetal blood is separated by only three or four cell layers (placental membrane) from maternal blood in the surrounding intervillous space.