Test 4

What is a uterine infection? Risks? Tx?

(metritis) in endometrium, myometrium, parametrium; common infection diagnosed postpartum Endometrium (endometritis), myometrium (myometritis), parametrium (endoparametritis) Risk: cesarean birth, long labor, frequent vaginal exams, prolonged rupture of membranes, tissue trauma, traumatic birth, postpartum hemorrhage, retained placental fragments, obesity, low socioeconomic status Tx: -Broad-spectrum antimicrobial therapy is treatment of choice. Prophylactic abx recommended for all cesarean births within 60 minutes before delivery, single dose)

What is the recommended contraception choice for post-bariatric surgery pts?

**IUD or Combined estrogen and progestin vaginal ring provides contraception while bypassing digestive system** -Oral contraception may not be absorbed -estrogen containing pills causes an increase of gallstones -Depo-Provera may cause weight gain

What are contraindications for COC?

*headaches (migraine w/ aura), gall bladder disease, DVT/stoke, smoking > age 35, smokers, breast cancer

What is the method of action for progesterone only pills?

*relies on cervical mucous thickening, works approx. 22 hours... if primarily sexually active in AM and PM, best to take in the middle of the day. Not as reliable at ovulation suppression as COCs. More important to take on time, every time. May be less effective if not consistently taking at the same time every day. However when taking along with LAM, the two together are almost 100%. **•Does not suppress ovulation as reliably as COCs; relies on the contraceptive effect of thickened cervical mucus.**

What GI changes are associated with pregnancy?

- Gas, constipation, dec. bowel sounds r/t slowed peristalsis -Decreased intestinal contractility r/t fluid reabsorption, displacement, and inc. progesterone -Heart burn from displacement and increased progesterone changes esophageal sphincter and gastric tone **INCREASED RISK OF GALL STONES R/T sluggish emptying of bile from gallbladder combined with increased cholesterol saturation.**

What skin changes are associated with pregnancy?

- Melasma (Cholasma Gravidarum) - Linea Negra - Striae Gravidarum

What are 2 complications of 1st trimester?

1. SAB 2. Ectopic

Average U.S. woman uses contraception for ___ years

30!!!

What percentage of unintended pregnancy end in abortion?

40%

What is the only birth control method that is 100% effective in preventing pregnancy?

ABSTINENCE

What does the use of non-oral BC avoid?

Avoiding 1st pass allows for lower doing and avoid interactions with other medications

Where can you not but a BC patch?

BREAST!

All barrier methods are?

COITUS DEPENDENT

What is a copper IUD?

Copper IUD: T-shaped device of polyethylene with copper wire around stem and arms; may stay in place for 10 years; sterile inflammatory response is a reaction to foreign body in reproductive tract

What is the difference between efficacy and effectiveness?

Efficacy: refers to "perfect use" Effectiveness: refers to "typical use"

What is male and female permanent sterilization?

F: •permanently blocking fallopian tubes. (or removing them) M: •(vasectomy): cuts or blocks both right and left vas deferens.

How do you eval poss. SAB?

FHT?, cramping/uterine contractions?, cervical dilation?, products of conception intact/in the uterus?, previous SAB?

When does rubella cause the greatest risk to fetus?

First 12 weeks.

_______ __________ ___________ is not always a sign of miscarriage or any problem at all

First trimester bleeding

What is the most common cause of neonatal sepsis and meningitis?

Group B Strep transmitted vertically through colonized vagina at birth GBS screening should be collected between 35 - 37 weeks gestation, positive GBS indicates need for intrapartum prophylaxis prophylaxis should also be provided if status is unknown, gestation is less than 37 weeks, ROM for 18 hours or longer, maternal temp >/= 100.4

What is HELLP syndrome?

HTN, elevated liver enzymes, low platelets •serious complication of preeclampsia; hypertension, elevated liver enzymes, low platelets. (hepatic rupture, DIC, eclampsia, abruptio)

Infective mastitis

Infection often by S. aureus spread from the mouth of the newborn to the cracks of the nipple. It usually presents as only one breast being red, hard, swollen, tender with fever and malaise. It may have purulent nipple discharge -Uncomfortable but doesn't hinder milk production. occasionally can occur bilaterally.; other risk factors: breast restriction (eg: bra too tight), vigorous exercise) risk factors: stress and fatigue; cracked nipples, plugged ducts, milk stasis; breast trauma; poor nutrition. tx:continue breast feeding, rest, fluids, nutrition, moist heat, NSAIDS, possible antibiotics (penicillinase-resistant penicillin or cephalosporin x 10-14 days) and milk culture. Decreasing frequency of feedings may increase milk stasis and subsequent mastitis, proper latch helps maintain nipple integrity.

What is common during 1st trimester?

Light spotting fairly common at 4 weeks gestation; often result of implantation

Leading cause of maternal morbidity and mortality?

PP hemorrhage

PROM VS PPROM VS SROM?

PROM: (prior to onset of labor): 8-10% labor follows w/in 24 hours most of the time. PPROM (preterm PROM): 50% will give birth w/in 1 week SROM (spontaneous rupture of membranes): may result (rarely 1.4 - 6.2 per 1,000) in umbilical cord prolapse, which is an emergency

What is coitus interruptus?

Pull out method

If bleeding is associated with pain or is heavy?

Should be eval'd immediately. Serial HCGs, if > 10-12 wks check FHT, pelvic exam

_____ ______ ________ 80% to 90% of all cervical cancers.

Squamous cell carcinoma

Heart displaced how in pregnancy?

Upward and left

Placenta previa

implantation of the placenta over the cervical opening or in the lower region of the uterus

What is a normal increase in daily calories for pregnant women?

increase of 350 calories per day.

What is uterine souflee?

maternal arterial blood arriving into the placenta

What is eclampsia?

new onset grand mal seizures in women w/ preeclampsia life-threatening complication of preeclampsia; tonic-clonic seizure activity, loss of consciousness, intracranial hemorrhage.

When does preterm birth occur?

occurs at 20-37 weeks gestation.

When can an ultrasound visualize fetal parts?

usually by around 8 weeks

What do barrier methods provide that other birth control does not?

•Dual protection against pregnancy and STIs. Contraindications rare.

What is the #1 cause of unintended pregnancy?

•Inconsistent/incorrect use of contraceptives.

What changes occur in the vagina/vulva from pregnancy?

•Increased vascularization of the vagina and pelvic viscera. •May increase a woman's libido and heighten her sexual response. •Vaginal pH increases. •Increased risk for varicosities with obesity, poor muscle tone, sedentary lifestyle.

Who gets endometrial cancer?

•Most frequently in postmenopausal women.

What are the surgical options for ovarian CA?

•total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal cytology, omentectomy, pelvic and para-aortic lymph node sampling, scraping of undersurface of diaphragm, multiple peritoneal biopsies, random biopsies.

What is contraceptive effectiveness?

•unintended pregnancies occur if method not used properly.

What is polyhydraminos?

-1.5-2 L amniotic fluid; may complicate fetal descent and inhibit effective labor. 60% idiopathic, can be associated w/ decreased fetal swallowing, fetal cardiac abnormalities, multiple gestation

Common causes of post partum infections?

-Aerobes (gram-negative and gram-positive bacteria). - Anarobes (cocci, bacteroides, etc.). -Others: Mycoplasma, Chlamydia, Neisseria gonorrhoeae.

What are common findings in postpartum examination?

-After-birth pains, diuresis/diaphoresis, constipation, hemorrhoids, perineal discomfort, breast engorgement.

What are common deficiencies associated with bypass?

-B12 deficiency, anemia, fat-soluble vitamin deficiency

What are the commonalities of unintended pregnancy?

-Between ages of 18 and 24 -Unmarried -Poor -Members of minority groups -Have not finished high school

Alterations in hormone levels cause?

-Breast changes -Fatigue -Urinary frequency -Nausea and vomiting

What counseling options are provided to women who have become unintendly pregnant?

-Carry pregnancy and parent child. -Carry pregnancy; place infant for adoption. -Have abortion. ** -Woman who needs to clarify thoughts and feelings about alternatives. -Preabortion counseling. -Nondirective approach; withhold personal judgment about woman's situation and decision. -Options counseling is a form of crisis intervention. -Explore how woman feels about pregnancy and options. -List risks and benefits, pros and cons, of options. -Help woman identify support systems/assess risks. -Assess risk of interpersonal violence. -Identify situations where child abuse present. -Address coercion regarding decision. -Arrange follow-up for patients who report they are unable to tell anyone about pregnancy. -Help woman reach decision or discuss timetable for decision making.

To prevent fetal rejection, the maternal immune system undergoes many changes such as?

-Cell-mediated response not as active. -Antigen-antibody response more active. -Relationship between these two altered.

How do you clarify values with a patient considering abortion?

-Clarify values regarding pregnancy options. -Self-assessment before clinical encounter; ongoing values clarification. -Explore women's decision to parent or place child for adoption. -Women with unintended pregnancies should receive care free from bias, nondirective, without judgment. -Areas of perceived conflict warrant examination.

What decreases incidence of endometrial cancer?

-Combined oral contraceptives (COCs) -Physical activity -Low-fat diet -Controlling other risk factors

When considering abortion, what is is considered?

-Decision is time sensitive. •*Do not rush patient, but decision regarding abortion, specifically medication induced abortion is time sensitive.

What are the risk factors of endometrial cancer?

-Estrogen therapy (ET) -Tamoxifen -Early menarche; late menopause -History of infertility or nulliparity -Obesity; chronic anovulation -Diabetes; high-fat diet -Ovarian cancer

What are the diagnostic signs of pregnancy?

-Fetal heart rate detected; *fetal outline and movements.

6 week post partum exam?

-General well-being, return to prepregnancy functions of cardiovascular, gastrointestinal, uterus, vagina/cervix/perineum, activity levels.

What are the GYN benefits following bariatric surgery?

-Improved fertility. -Reduced risk of hypertensive disorders, gestational diabetes, and large for gestational age infants.

When should patients avoid getting pregnant after bariatric surgery?

-Instruct to wait 12-24 mo post sx for pregnancy

What are common side effects due to nutritional and absorptive disruptions following bariatric surgery?

-Iron and calcium def. -Iron def for menstruating females -Bone density for menopausal or limited weight bearing pts Can refer to surgeon and nutritionist for f/u

What are symptoms of PPMAD?

-Mild to severe symptoms: hormonal, social/economic stressors, lack of sleep, demands of new infant, role adaptation, family needs, history of mental illness.

What risks are associated w/ pregnancy after bariatric sx?

-Nutrient deficiencies. -Nausea and vomiting disrupt band placement or cause malnutrition.

What hx should be obtained from a bariatric sx pt?

-Routine history -Date of bariatric surgery -Type of bariatric surgery -Last follow-up visit with bariatric surgeon -Maximum amount of weight lost; current weight -Dietary habits and restrictions -Medications and supplementations -Menstrual history -Contraception use -Psychological history

What are the probable signs of pregnancy?

-Softening, darkening of cervix; uterine softening, enlargement; ballottement; positive pregnancy test. NON-SYMPTOM - OBJECTIVE

What is the responsibility of a provider discussing options for an unintended pregnancy?

-Uphold patient rights and autonomy. -Treat patients with respect and compassion. -Have adequate knowledge and skills to deliver safe, quality care.

How is unintended pregnancy prevented?

-Use contraception. -Improve contraception education and counseling. -Remove financial barriers. -Emergency contraception (EC).

How is ectopic pregnancy treated?

-Use of methotrexate to dissolve products of conception and avoid tubal rupture; surgical resolution most common.

What are risks for SAB? Types?

-advancing maternal age, endocrine disorders, viral and bacterial infections, anatomic reproductive disorders, chronic diseases. threatened, inevitable, incomplete, complete, missed, recurrent

What is HSV associated w/ in pregnancy?

-associated with SAB, preterm birth, intrauterine growth retardation; cesarean birth recommended for women with active lesions. Routine screening for HSV in pregnancy is not recommended. However, screening should be performed upon identification of high risk. Suppressive therapy beginning at 36 weeks gestation may prevent need for c/secion, which is recommended in the presence of active lesions.

What is puerperal infection?

-bacterial infections after child birth -occurs within 28 days of abortion or delivery -found inside or outside of vagina -Fever greater than 100.4°F in first 10 days postpartum*. -Generally infection of genital tract; but can be respiratory infection, UTI, mastitis, or dehydration. -May result from cardiovascular or thromboembolic events or other conditions.

Gonorrhea is associated with?

-infections associated with ectopic pregnancy, preterm birth, premature rupture of membranes; transmission possible during vaginal birth. Screen ALL women 25 and under at first visit; screen women over 25 who are at risk at first visit. If risk continues, retest in 3rd trimester. No test for cure for cervical, test for cure for pharyngeal if alternative treatment regimen.

What are the consequences of exposure to rubella?

-miscarriage, stillbirth, birth defects such as deafness, cataracts or glaucoma, cardiac defects, microcephaly, intellectual development disorder, bone lesions, thrombocytopenia purpura.

Trich causes what in pregnancy?

-potential premature rupture of membranes, low birthweight. increases risk for transmission of HIV; no recommended pregnancy screening, test when symptoms, screen based on risk

HIV causes what in pregnancy?

-risk of failure to thrive, upper respiratory infections, chronic diarrhea, dermatitis, thrush in infants. antiretroviral therapy, avoiding antepartum procedures, and avoiding breastfeeding can significantly reduce maternal/fetal HIV transmission (from 30% to 2%); Screen ALL women at first visit

Hep B associated with?

-spontaneous abortion (SAB) and preterm birth. screen ALL women at first visit; vaccinate women AT RISK during pregnancy

What are the risks associated with sleeve gastrectomy?

-staple line leak, pulmonary embolism, incisional hernia, wound infection, malnutrition, and vitamin/mineral deficiencies.

What does syphils cause?

-transplacental transmission; exposure prior to 28 weeks increases risk of rhagades, hydrocephaly, saddle nose, saber shin, Hutchinson teeth, diabetes, preterm birth, fetal death. Screening ALL women at first visit; Screen again after 28 weeks WOMEN AT RISK/women who live in area with high syphilis morbidity. ONLY treatment recommended during pregnancy is penicillin.

What are symptoms of preterm birth?

-uterine cramps, backache, diarrhea, increased vaginal discharge, vaginal bleeding.

When do blood levels regulate in postpartum women?

1 week some through blood loss, some through mobilization of extracellular fluid. Changes in increased coagulability take longer to normalize (up to 6 weeks)

2nd trimester complications?

1.) Cerv insufficiency 2.) PTB 3.) GDM 4.) Blood Incompatibility 5.) Oligo/Polyhydramino

What are the 3 options for unintended pregnancy?

1.) Continue pregnancy, raise child 2.) Adoption after birth 3.) Abortion (Multiple types)

What is the difference between COC and progesterone only?

1.) Just progesterone - no estrogen. 2.) Used continuously - no break like w/ combined 3.) Safer for women who cannot have estrogen (like those who are breast feeding or have hx of breast CA) 4.) DOES NOT PROVIDE CYCLE REG. LIKE COMBINED

What are 3rd trimester complications?

1.) Preeclampsia 2.) HELLP syndrome 3.) Eclampsia 4.) Placenta previa 5.) Abuptio placentae 6.) Placenta accreta

How long does involution of uterus take?

10 days to 6 weeks (pelvic organ by 10-14 days)

Bladder tone and dilation of renal track?

3-8 weeks. Bladder tone and reduced dilation of urinary tract during 6-8 weeks postpartum, however trauma during delivery may increase risk for infection. GI: Decreased progesterone = improving tone relieving reflux and constipation w/in a few days. However, trauma during deliver, lack of fluids, decreased mobility after delivery may contribute to constipation.

How much does cardiac output increase in pregnancy?

30%-50%.

What percentage of reproductive organ cancers are vulvar?

4%, usually curable

______% of pregnancies in the US are unintended.

45%

How much is lung capacity reduced in pregnancy?

5% Risk for hyperventilation and dyspnea increased.

-Nearly _____% of all women seeking AB have had at least one other AB in the past

50%

What percentage of pregnancy is unplanned?

51%

•Most physical restoration takes place in the first __ weeks postpartum.

6

What state regulations have decreased the number of abortions?

7 states now mandate that a woman has US before having an AB Many states, including GA have mandated counseling and "wait time" (24 hours+) before having an AB. Only up to 20 weeks. HB481 bill was signed by Governor Kemp on May 7, 2019, bringing into effect one of the strictest abortion laws in the country at the time. The bill would prohibit abortions after a heartbeat can be detected in a conceptus, which is usually when a woman is six weeks pregnant. GA law requires informing parent of a minor if considering AB

What makes up majority of blood volume increase in pregnancy?

75% is plasma

What age range has a higher incidence of vulvar cancer

80% in women older than 50

Fatigue associated with pregnancy peaks?

9-12 weeks

What is oligohydraminos?

<500 mL amniotic fluid at 40 weeks gestation; may result in maternal hypertension, placental insufficiency, maternal renal disorders, post-term pregnancies, fetal renal or heart abnormalities.

puerperal morbidity?

A maternal temperature of 38 degrees C (100.4 degrees F) or higher on any 2 of the first 10 postpartal days, excluding the first 24 hours. The temperature is to be taken by mouth at least four times per day.

What does amniotic fluid do?

Amniotic fluid helps maintain uterine temp, develop fetal lungs, allows for adequate fetal movement, morphologic development, and protects fetus from trauma and provides a barrier from infectious agents.

What can help curb n/v in pregnancy?

Avoid foods or cooking that triggers illness Small, frequent meals Saltines, Ginger Folic acid only instead of a multivitamin

How is a vulvar cancer definitely diagnosed?

Biopsy with TNM staging

When does blood volume increase in pregnancy?

Blood volume peaks 30-34 weeks; increases 30%-50%, 1,110-1,600 mL

What does COC increase the risk of?

Breast cancer

Whats the most common risk factor for post partum infection?

C-Section

What is the 4th most common cancer in women?

Cervical CA. If detected early, 5 year survival rate is 100%. •HPV most causative agent in cervical carcinogenesis; most common sexually transmitted infection (STI) worldwide.

•Pregnancy for adolescents who have had bariatric surgery _______ the rate in adolescent population.

DOUBLE Discuss contraception!!

Is the abortion rate increasing or decreasing

Decreasing

Goal of treatment of hyperemeis gravidarium?

Goal of treatment of HG - correct dehydration/electrolyte imbalance

What is a Mirena, Skyla, Kyleena and Liletta?

IUDS that contain levonorgestrel but no copper; may stay in place for 5 years (Mirena and Kyleena) or 3 years (Skyla and Liletta).

Weight loss therapy can also treat what in women?

Infertility. Obesity can negatively affect gynecologic function.

What vaccine is recommended prior to conception?

MMR - cannot give during pregnancy it is a live, attenuated vax. Prenatal screening at first visit (IgG for immunity); pregnant women with symptoms should have viral culture, PCR, or IgM test DO NOT GIVE VARICELLA VAX DURING PREG - exposure causes congenital defects and illness throughout pregnancy, including up to fetal death, immune globulin available and can be effective.

What is lactational amenorrhea?

Maintained nursing stimulates prolactin production, which inhibits the secretion of FSH and LH. •exclusively breastfeeding infant younger than 6 months.

What are the 3 types of bariatric surgery?

Malabsorptive Restrictive Combined

What provides passive immunity for the fetus?

Maternal immunoglobulin G (IgG) antibodies

What is a sign of congenital rubella syndrome?

May be delayed for 2-4 yrs hearing impairment most common single defect

About 30% of implanted embryos, 15% of clinically recognized pregnancies ________.

Miscarry

Risk of failure of COC increases with?

Missed pills

Does hormonal BC accumulate in the body?

NO! That's why you have to take it at the same time every day

What are the types of combined contraceptives?

Oral - the pill Transdermal patch Vaginal ring

What is milk stasis?

Overabundance of milk can lead to inadequate emptying. •In this case, let down can overwhelm the infant sometimes causing choking sounds or making them unlatch and turn away. (if these things are occurring, evaluate infant for reflux/swallowing problems as well)

Risk factors for ectopic pregnancy?

PID, infertility/ART, history of abortion (increased w/ complication)

What are the non hormonal categories of birth control?

Physiologic Barrier Permanent Copper IUD

What are significant cardiac changes related to pregnancy?

Physiologic anemia Decreased vascular resistance, related to hormones, and compression of the vena cava contribute to lower extremity edema. Decreased vascular resistance also contributes to gingival swelling and bleeding.

What is abruptio placentae?

Premature separation of a normally implanted placenta after the 20th week but before birth •associated hemorrhage life-threatening. obvious or occult: obvious = vaginal bleeding Risk factors: hypertension, history of abruption, circumvallate placenta attachment, abdominal trauma, uterine cavity deformities, short umbilical cord, smoking and cocaine use. Typically associated with sudden, sharp, constant pain and bright red vaginal bleeding ( pain is not intermittent or waxing/waning like contractions)

What is depo-provers?

Progesterone only injection given every 13 weeks. R/T bone mineral density loss and weight gain. Return of ovulation varies, ranging from 15 to 49 weeks after the last injection.

Women with symptoms of preterm birth are instructed to?

Reduce physical activity

How often do you change a vaginal ring?

Ring left in place in vagina for 21 days; removed for 1 week; provides steady delivery of hormones

Hormonal birth control does not provide?

STI protection

If hCG level slowly increases and does not double?

SUSPECT ECTOPIC PREGNANCY

When should women be screened for PPMAD?

Screening should begin at the first postpartum visit. Validated examples: EPDS (Edinburgh Postnatal Depression Scale; PDSS (Postpartum Depression Screening Scale), PHq-9 (Patient Health Questionnaire), BDI (Beck Depression Inventory), CED-D (Center for Epidemiological Studies' Depression Scale) Appropriate identification and treatment/referral, coordinated care important

What is a spermicide sponge?

Single use, polyurethane, contains spermicide Moisten it, place for 24 hours Few toxic shock syndrome cases

What are majorities of vulvar cancers diagnosed as?

Squamous cell carcinomas

What are presumptive signs of pregnancy?

Subjective signs perceived by the woman -Amenorrhea, nausea, vomiting, increased urinary frequency, excessive fatigue, breast tenderness.

What type of hypotension occurs in pregnancy?

Supine *and to the left, supine hypotension increases due to compression of the inferior vena cava and aorta; this is why left lateral position recommended for rest

*Women still need gyn exams over age 65, after menopause, after hysterectomy. T or F?

T - R/O vulvar CA

When are the cervix and vagina back to prepregnancy state?

The cervix (within about 1 week) and vagina (3-4 weeks)

What is Biliopancreatic bypass, with or without duodenal switch (BP/DS)?

The first step is sleeve gastrectomy in which about 80 percent of the stomach is removed, leaving a smaller tube-shaped stomach, similar to a banana. However, the valve that releases food to the small intestine (the pyloric valve) remains, along with a limited portion of the small intestine that normally connects to the stomach (duodenum). The second step bypasses the majority of the intestine by connecting the end portion of the intestine to the duodenum near the stomach. A BPD/DS both limits how much you can eat and reduces the absorption of nutrients, including proteins and fats.

What increases likelihood of UTI?

Urinary stasis

How can pregnancy be detected at home?

Urine pregnancy tests are inexpensive, noninvasive, reliable, and easy to perform

•About 47% of postpartum ______ cases occur after vaginal delivery. Postpartum women, surgical or vaginal, still are at risk due to __________ ________ (hypercoagulability, stasis, vascular trauma).

VTE Virchow's triad •responsible for 9.3% of pregnancy-related deaths.

What causes a genital tract or vulvar hematoma?

Vascular trauma during birth

What is the ratio of obese women to men?

Women who are obese outnumber men by almost a 3:1 ratio •The majority of individuals undergoing bariatric surgery are women of reproductive age.

If hCG level is >3,000?

a gestational sac should be visible on ultrasound (If not visible in the uterus, look elsewhere)

postpartum psychosis?

a rare and severe form of depression that occurs in women just after giving birth and includes delusional thinking and hallucinations

What are the symptoms of ovarian CA

abdominal bloating and discomfort, dyspepsia, fatigue or weakness

What are the risks associated with biliopancreatic bypass w or w/o duodenal switch?

anastomotic leak, respiratory complications, stomal ulceration, wound-related complications, incisional hernia, malnutrition, and vitamin/mineral deficiencies.

What are the risks associated with adjustable gastric banding?

band slippage, band erosion, esophageal dilatation, bleeding, pulmonary embolism, incisional hernia, wound infection, and vitamin/mineral deficiencies

What are the pregnancy associated breast changes?

breast skin thins and striae develop; alveoli become progressively distended.

What is placenta accreta?

condition in which villi adhere to myometrium; vaginal bleeding most common symptom; risk increases with number of cesarean deliveries.

What is emergency contraception?

contraceptive method offered if unprotected intercourse (UPI) occurs at any time in the menstrual cycle. •Yuzpe, levonorgestrel, and ulipristal acetate emergency contraceptive pill (ECP) and copperIUD can be used within 120 hours of UPI.

What is Chadwick's sign?

darkening (bluish/purplish color) of cervix

What does COC decrease the risk of?

decrease risk for ovarian and endometrial cancers

What is fertility-awareness based methods?

determine when woman is most fertile and use abstinence or barrier contraception during that time.

Placenta accreta

direct implantation into myometrium without intervening decidua -> severe bleeding at birth, need hysterectomy.

What is the most common gynecologic cancer?

endometrial cancer

What most commonly causes UTI in pregnancy? Do we treat in asymptomatic pregnant women? What do we use to treat?

group B Strep and E. coli most common, encourage adequate water intake, left lateral lying position for better renal perfusion, kegel exercises to decrease frequency/urgency YES! ALWAYS TREAT UTI IN PREGNANCY •Decreased urinary tract peristalsis may cause urinary tract infection (UTI)* and asymptomatic bacteriuria (ASB)*. Timethoprim contraindicated during pregnancy (therefore Bactrim). Can use Keflex. DDx for UTI: Gestational DM and ROM (rupture of membranes)

How should HCG levels change with pregnancy?

hCG level should double in 48 hours (serial hCG)

What mental disorders are very prevalent in bariatric surgery populations?

high rates of depression and anxiety. higher rates of psychiatric disorders and preexisting eating disorders (binge eating). •Mood disorders recur, causing weight gain. •Controversial theory: After bariatric surgery, woman transfers food addiction to other harmful addiction. May be increased risk of suicide after surgery in those with co-existing alcohol abuse and DM Eating behaviors increase when substance abuse minimal; risk of substance abuse behaviors increases when eating behaviors decrease.

What are the positive mental health benefits after bariatric surgery?

improved body image, less pain and fatigue, increased marital satisfaction, and improved sexual functioning

What is cervical insufficiency?

inability of the cervix to remain closed during pregnancy risk fx: increased risk w/ history of LEEP, cervical conization, dilation during pregnancy termination; possible other contributing factors: birth trauma to cervix, fetal loss 14 weeks or greater, multiple pregnancy terminations Serial ultrasounds may also be performed beginning around 16 weeks (measure length of cervix) tx: reduce sexual activity, avoid breast stimulation, increase hydration; should be followed closely for cervical change as well and for fetal well being (mother can monitor fetal movement)

What is related to respiratory congestion in pregnancy?

increased edema of pharynx and larynx

What causes breast tenderness in pregnancy?

increased progesterone and estrogen.

Post partum thyroiditis?

inflammation of the thyroid gland. can present anytime during the first year after delivery, but usually in 1-4 months. Hypo, hyper, or alternating... S/S may be subtle.

HPV in pregnancy?

large lesions can obstruct introitus; cesarean birth not usually necessary; newborns at small risk for respiratory papillomatosis. treatment for HPV/warts w/ topicals such as podofilox, podophyllin, sinecatechin is not appropriate during pregnancy and there is limited data to support the use of imiquimod. Most lesions can be observed carefully and treated after delivery.

Chaldymia exposure in fetus causes?

major cause of infertility; associated with ectopic pregnancy, premature rupture of membranes, postpartum endometritis, preterm birth, stillbirth. Screen ALL women 25 and under at first visit; screen women over 25 who are at risk at first visit. Retest in 3rd trimester. If positive, test for cure in 3-4 weeks after treatment, then again in 3 months.

When is medical intervention needed in spontaneous abortion?

medical interventions necessary with excessive bleeding or cramping

What is gestational trophoblastic disease?

molar pregnancy ): may appear as missed SAB; may have severe n/v, vaginal bleeding/passing tissue, no FHTs, high hCG levels (Referral maternal fetal medicine and possibly Gynecologic Oncologist, since these can be malignant)

Common 1st trimester complications?

nausea, vomiting, irregular menses, increased urination, breast tenderness

What does postpartum mean?

occurring after childbirth, it is returned to pre pregnant state & able to reproduce again •begins when the placenta is delivered and continues to 6-8 weeks postpartum.

What is CA 125 used for?

ovarian cancer tumor-associated antigen (glycoprotein);

What is hyperemesis gravidarum?

persistent vomiting not related to other causes, acute starvation (usually large ketonuria), and weight loss. may cause ketonuria and dehydration, electrolyte imbalance, weight loss. More common in first pregnancy, multiple gestations, and molar pregnancies. - check B-hCG and U/S to r/o molar pregnancy If "morning sickness" persists after the first trimester, think hyperemesis gravidarum Tx: (doxylamine succinate/pyridoxine hydrochloride (Diclegis))

What is placenta previa?

placenta obstructs cervical os. - may cause painless vaginal bleeding and management of bleeding is likely #1 goal if heavy/causing anemia/symptoms; do not do cervical exam Malpresentation, placenta accreta, abruption, postpartum hemorrhage, DIC, etc. can occur If partial/low lying occurs early in pregnancy, may migrate higher/resolve as uterus/fetus grows.

placental abruption

placenta separates prematurely

•Reproductive life plan is key to?

planning a family, clarifying goals, and using contraception more consistently.

What is lochia?

postbirth uterine discharge •, takes 4-8 weeks.

What is combined bariatric surgery?

produces small stomach pouch and bypasses parts of digestive system.

What are the types of progesterone only BC?

progestin-only pill (POP), injection, implant, and *FOUR progestin-containing intrauterine devices

What are other uses of COC?

regulate menstrual cycles; useful in management of abnormal bleeding patterns

How do the kidneys change in pregnancy? What is their function?

regulates increases in blood and extracellular fluid volume, excretes maternal and fetal waste products, and conserves essential nutrients Kidneys are displaced and increase in size Effects of progesterone decrease bladder tone; can lead to urinary frequency and incontinence

What education is provided for preeclampsia?

self care and monitoring very important: fetal movement counts beginning at 28 weeks

What is the diaphragm?

shallow dome-shaped cup that is inserted in the vagina to cover the cervix; woman-controlled method; provides protection against some STIs Measured and fitted Use with spermicide Worn 24 hours

What is a female condom?

sheath with flexible ring at both ends.

What is a cervical cap?

smaller version of a diaphragm high degree of displacement and failure Adhere by suction over the cervix. Fem Cap-3 sizes based on pregnancy and birth hx Thin layer of spermicide on edges, smaller than diaphragm Keep in place up to 48 hours

what is godell's sign?

softening of cervix

What is Hegar's sign?

softening of lower uterine segment *palpable after 20 weeks

Lactogenesis

the process of developing the ability to secrete milk and involves the maturation of alveolar cells •Breast size has no impact on breastfeeding, however delayed initiation of breastfeeding, c-section delivery, increased stress, ineffective suckling, some medical conditions and obesity can affect milk production and in turn impact successful continuation of breastfeeding. **Key here is early identification of problem and consultation of lactation specialist.

How does a uterus bend in Hegar's Sign?

uterus bends in anterior direction on lower uterine segment first start to fill a balloon with air.

Levonorgestrel ECP is available ____________ ____________, and only to women ____+.

without prescription 17y/o+

How much do breasts increase in oz during pregnancy?

•12-ounce total increase in breast weight over term of pregnancy.

What is the normal pill pack for COC?

•21-24 days active COCs followed by 4-7 days inactive pills or no pills. (some w/ 84 active, then 7 inactive)

How much does oxygen consumption increase in pregnancy?

•30% increase in oxygen consumption may compromise respiration in those with chronic asthma, obesity, or maternal smoking.

What is preeclampsia?

•6%-10% of pregnancies; maternal high blood pressure. -Maternal risk of renal or liver failure, disseminated intravascular coagulopathy (DIC), abruptio placentae, emergent operative birth, death. Systolic 140 or higher, Diastolic 90 or higher, and proteinuria +1 on two occasions 4 hours apart OR 300mg or greater in a 24-hour time frame OR absent proteinuria BUT with the presence of thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or central nervous system or visual changes.

What is Parovirus B19? What does it cause?

•: fifth disease; half of women are immune; presents with rash and joint pain for mother. -In 5% of pregnant women, body stops making red blood cells, resulting in transient aplastic crisis, hydrops fetalis, congenital or persistent anemia, pure red cell aplasia.

Nipple candidiasis?

•: infection can pass between mother and nursing child; both should be treated. typically occurs bilaterally and is associated w/ infant thrush. Both mother and child should be treated simultaneously.

If genetic or fetal screenings are abnormal?

•Abnormal findings warrant further diagnostic testing, amniocentesis.

What are common presenting symptoms of endometrial cancer?

•Abnormal uterine bleeding; character of bleeding, pattern of flow, number of pads used. •Metastatic spreads to pelvic and para-aortic nodes. POST MENOPAUSAL FEMALE WHO BEGINS BLEEDING RANDOMLY - RED FLAG DO TVU DURING BEGINNING OF CYCLE WHEN ENDO LINING IS THINNEST

What are common presenting symptoms of cervical cancer?

•Abnormal vaginal bleeding is common. *post-coital bleeding

What are the risk factors for ovarian CA?

•Advancing age significant risk factor; increasing at menopause. •family history in first-degree relative; BRCA1 or BRCA2 genetic mutation.

Breast Feeding?

•American Academy of Pediatrics supports breastfeeding of newborn as method of choice. •Breastfeeding initiated immediately after birth increases likelihood of milk production. •*Positioning choice increases likelihood of breastfeeding success. Cradle, cross-cradle, football, semi-reclining, Australian positions

How can vulvar cancer be prevented?

•Avoid exposure to HPV; vaccination. •Seek treatment for vulvar itching caused by chronic vulvar diseases. •No smoking; routine vulvar self-examination.

What should pregnant women avoid in diet?

•Awareness of foods to avoid*: unpasteurized foods, beverages, and raw meats. •Limiting caffeine.

What is the criteria for weight loss surgery?

•BMI of 40+ is extremely obese and meets criteria for weight loss surgery if no medical problems. •BMI of 35+ meets criteria for weight loss surgery if accompanied by high-risk comorbid disease.

What medical history is important to note during pregnancy?

•Birth control used at conception. •Prior obstetric history. •Infectious diseases history; can receive immunizations: flu shots, Tdap. •Decreased immune response. •Genetic history for risk factors; paternal history. •Substance use/abuse; medications; toxic exposures.

What blood tests are commonly performed with pregnant women?

•Blood tests: hemoglobin, hematocrit; type and Rh factor; antibody screen; rubella titer; HIV; syphilis test. •Urine tests: culture; chlamydia, gonorrhea. •Other blood tests: diabetes screening; varicella antibodies; Hepatitis C; thyroid-stimulating hormone; maternal genetic testing. **Gonorrhea - after age 25 only w/ risk factors (multiple partners, partner w/ a male partner or multiple partners)**

What is the most common type of bariatric surgery in the US?

•Combined procedure, roux-en-Y gastric bypass (RYGB), is most common in the U.S.

What genetic testing is done for pregnancy?

•Cystic fibrosis; sickle cell carrier. maternal testing for carrier status done first, only necessary once in lifetime. If positive, father of baby tested next. Baby only tested if both positive. •Autosomal recessive conditions; both parents. 1st trimester

What fetal screening is done during pregnancy?

•Down syndrome, aneuploidies, abnormalities in chromosome number. maternal serum markers, NIPT, Quad screening (2nd trimester), ultrasound (nuchal translucency, anatomy ultrasound) 1st trimester

What is the #1 risk factor for cervical cancer?

•Early age first intercourse risk factor for HPV; developing cervix more likely to be infected.

What is an ectopic pregnancy?

•Ectopic implanting of fertilized egg in Fallopian tube; 2% of pregnancies; potentially life-threatening; treatment with medication or surgery.

What are m/s changes associated with pregnancy?

•Effects of progesterone, estrogen, and relaxin on ligaments and joints; relaxation of pelvic structures. •Posture: shifting center of balance caused by the enlarging uterus. •Gait changes, sciatica, discomfort of the symphysis pubis, and stretching/pain of uterosacral and cardinal ligaments common. Circumference of neck enlarges. (In addition to circumference of chest getting bigger as previously discussed)

What is important to note during physical exam of pregnant female?

•Elements of routine physical exam. •Oral cavity assessment; periodontal disease. •Pap test; manual exam of uterus, fundus. •Fetal heart tone monitoring: 120-160 beats per minute*. *FHTs likely not audible with doppler before 10-12 weeks.

What are the neuro/psychological changes associated w/ pregnancy?

•Emotional lability and irritability due to shifting hormone levels. •*Cognition: decreased attention span, decreased concentration, memory lapses reported. •Sleep alterations increase risk of depressive mood, stress. •Potential optic, otic changes: corneal edema, hyposensitivity, plugged ears, reduced hearing, vertigo.

What are the risks associated w/ abortion?

•Emotional, relational, spiritual •Physical -Bleeding, passing large clots -Infection -Retention of fetal tissue -Scarring or damage to cervix -Infertility

What should be discussed at post partum visit?

•Encourage exercise/physical activity to aid in restoration of muscle tone. •Fatigue is common. be on the look out for abnormal fatigue, anemia, infection, etc. •Sexual intimacy can resume when woman is ready*. *Episiotomy, C-Section may require delay in return to intercourse •Choice of contraception dependent on individual factors: breastfeeding, risk for venous thromboembolism, lifestyle factors.

What patient education is important to provide to pregnant women?

•Ensure access to resources. •Encourage lifestyle modifications as necessary. •Provide information on medications, chemical exposure, and safety. •Warning signs: bleeding*, abdominal pain, extreme nausea, and vomiting.

What social history is important to note during pregnancy?

•Ensure adequate food and shelter. •Secure, nondangerous environment; free of physical, mental, sexual abuse. Avoidance of risky home environment or leisure activities Does teen feel safe telling parents? Is patient in safe, non-abusive relationship/situation? Adequate heat, food, shelter? Insurance needs?

What pt education should be provided to post bariatric surgery pts?

•Follow up regularly with surgeon after surgery. •Vitamin and mineral supplements. •Refrain from pregnancy for 12-24mo period after surgery*.

How does the fundus grow during pregnancy?

•Fundus rises out of the pelvis; enlarges approximately 1 cm per week.

How can you prevent HPV?

•HPV vaccines: *high efficacy preventing cervical precancers caused by HPV types 16, 18.

Which gynecologic cancer has the highest mortality rate?

•Highest mortality rate of all gynecologic cancers. •Prognosis poor; early diagnosis infrequent; 5-year survival rate 44%. •Epithelial ovarian carcinomas: 80%-90% of diagnoses.

What causes the pelvic floor to relax in pregnancy?

•Increasing levels of progesterone and relaxin soften pelvic floor ligaments and muscles. Further stretched by the gravid uterus and vaginal delivery

If found to be cancerous, how is cervical CA treated?

•Lifelong surveillance at regular intervals. •Treatment of advanced cervical cancer: surgery, radiation therapy, chemotherapy.

What changes are seen in the endocrine system in pregnancy?

•Mild enlargement of the thyroid. •Pituitary gland size increases by factor of 3. •Basal metabolic rate increases 20%-25%. •Insulin resistance, obesity pose greater risk for gestational diabetes*. •Increased prolactin and oxytocin amounts released throughout pregnancy.

What bloodwork is done routinely for post bariatric surgery pts?

•Monitor nutritional status. -Complete blood count; albumin -Serum vitamin B12 -Iron; ferritin level -Phosphorus, calcium -Folate, homocysteine level -Thiamine, zinc -25-hydroxyvitamin D level -Copper; selenium; vitamins A, B2, B6, C, E, and K; and niacin

Is there a screening test available for endometrial cancer?

•No screening test currently available; endometrial biopsy; transvaginal ultrasound. •D & C gold standard for assessing uterine bleeding; diagnosing endometrial cancer.

What testing is done for cervical cancer?

•Pap test; liquid-based cytology; STI testing; wet mount preparation. •Ruled out prior to diagnosing cancer: cervicitis or STI, vaginitis, cervical polyps, pelvic inflammatory disease.

How often do you change a BC patch?

•Patch changed weekly on same day of week for 3 weeks; no patch worn for 1 week.

What causes common issues post pregnancy like hemorrhoids, urinary incontinence etc??

•Pelvic floor changes during pregnancy/birth may contribute to urinary and fecal incontinence, hemorrhoids, dyspareunia, uterine prolapse.

How do you estimate date of birth?

•Pregnancy dated from first day of last menstrual period. •Nägele's rule: Add 7 days to first day of LMP, then subtract 3 months. •Ultrasound used to date pregnancy; date accuracy declines as pregnancy progresses.

How is unintentional pregnancy diagnosed?

•Pregnancy test performed for diagnosis. •Estimate gestational age; bimanual examination for uterine size or ultrasound.

All pregnant women should take?

•Prenatal vitamin supplements, especially iron and folic acid.

What are breast changes associated with pregnancy caused by?

•Prompted by hormonal changes. •Preparation for lactation. •Estrogen and progesterone cause proliferation in ducts and glandular tissue. PIF (prolactin-inhibiting factor) and increasing estrogen prevent lactation until after delivery despite increasing levels of prolactin.

What increases risk of vulvar cancers?

•Related to human papillomavirus (HPV) infection or vulvar intraepithelial neoplasia (VIN) disorders.

What are the cervical changes associated with pregnancy?

•Softened cervix probable sign of pregnancy. •Mucus plug develops in the os. •Effacement: softening and thinning of cervix at term. •Uterine contractions stimulates cervical dilation.

How does uterine wall thickness change with pregnancy?

•Solid organ becomes thin-walled, hollow. •Wall thickens from 10 mm to 25 mm in first 16 weeks; thins to 5-10 mm by term.

What is the progestin implant?

•Subdermal progestin implant among most effective methods. •Long-acting reversible contraceptive. •Single-rod implant releases etonogestrel slowly over 3 years. •Clinicians need training to ensure appropriate placement and skilled removal. •Ovulation returns within 6 weeks after removal.

How is vulvar cancer treated?

•Surgical resection standard treatment. •Chemotherapy for metastatic disease. •Counseling for expression of grief over loss of normal sexual function.

How is ovarian CA diagnosed?

•TVUS, CA-125 blood test

Treatments for endometrial CA?

•Treatment options: hysterectomy, radiation therapy, chemotherapy, hormonal therapy. •Most recurrences found within 3 years.

Type 1 vs Type 2 endometrial CA?

•Type I (estrogen-dependent endometrial cancer): most common; excess of endogenous or exogenous estrogen, unopposed by progesterone. •Type II: 10% of cases; unrelated to estrogen or endometrial hyperplasia; endometrium atrophic or has polyps.

What are the symptoms associated w/ vulvar CA?

•Vulvar lump or mass with prolonged history of vulvar pruritus. •Vulvar bleeding, discharge, dysuria, pain. **50% of women with vulvar cancer asymptomatic**

How is cervical cancer diagnosed?

•Well-defined premalignant phase; identified through cytological examination of exfoliated cells (Pap test); confirmed on histological examination. If pap abnormal - refer for Colposcopy

What is toxoplasmosis? What does it cause?

•a parasite; food-borne or animal-to-human transmission. undercooked shellfish, cat litter/feces, unwashed produce -Fetal exposure to infection may result in vision or hearing loss, neurologic delays, seizures.

What are the physiologic methods of birth control?

•abstinence, coitus interruptus, lactational amenorrhea method (LAM), and fertility awareness-based (FAB) methods.

Postpartum blues?

•affects nearly 80% of all postpartum women, is transient, is short-lived.

What are the types of abortion?

•aspiration, medication, surgical, labor-induction methods. •Vacuum aspiration abortion: most common method of pregnancy termination-1st trimester

When can PP depression occur?

•at any time within the first year postpartum.

What is malabsorptive bariatric surgery?

•bypass parts of digestive system and some reduction of stomach pouch.

What is gestational diabetes? Risks? Complications?

•carbohydrate intolerance resulting in hyperglycemia; considered high-risk pregnancy. risks:-Maternal age; ethnicity; obesity; hypertension; previous history of GDM. complications: -Higher incidence of SAB, pyelonephritis, preterm labor/birth, preeclampsia; stillbirth; birth trauma, neonatal hypoglycemia, hyperbilirubinemia. All women should be screened between 24-28 weeks, women w/ BMI > 30, first degree relative w/ DM or strong family history, prior history of GDM or other impairment of glucose metabolism should be screened 1st trimester. (if that is neg, rescreen 24-28 weeks)

Breast abscess?

•from untreated mastitis or infection: -Usually requires antibiotics. -Breastfeeding on unaffected side may still occur, encouraged on affected side if position of abscess/drain(s) does not interfere w latch.; pumping is an alternative.

What is cytomegalovirus? What can it cause?

•herpesvirus; transmitted transplacentally, through maternal fluids, breastfeeding; flulike symptoms for mother. possible mental retardation, hearing loss, cerebral palsy.

Puerperal wound infections?

•infections at site of laceration, episiotomy, abdominal incision. -Wound infection management depends on location and severity.

What in subinvolution?

•interrupted uterine restoration to pre-pregnant size during standard postpartum time frame. Placental site subinvolution/postpartum hemorrhage can present as late as 2 weeks.

What is contraceptive efficacy?

•likelihood that unintended pregnancy will occur even when method used consistently and as prescribed.

What immunity is responsible for placental protection?

•macrophage cells, lymphocytes, phagocytes, cytokines. (cell mediated response, ironically - phagocytes, antigen specific cells (T-Cells), cytokines, etc...)

What are the barrier methods of birth control?

•male condoms, vaginal barrier methods, and spermicides.

What are LARCs?

•methods that prevent pregnancy for extended periods of time with no effort from the user. (that are reversible) •Includes IUDs and subdermal implants. •Highest effectiveness of all contraception methods.

What is blood incompatibility?

•mixing of mother's Rh-negative blood with fetus's Rh-positive blood can cause IgG antibodies to the Rh (D) antigen; risk to subsequent pregnancies. ABO and Rh screening at first prenatal visit, antibody titer during 2nd trimester for all Rh negative mothers, if titer negative administer Rhogam, second dose within 72 hours of birth of Rh positive infant (Rhogam indicated ANY time potential for mixing of blood occurs: placental abruption, prenatal procedures such as amniocentesis, SAB/IAB, ectopic, hydatidiform mole, abdominal trauma, external cephalic version, etc.)

What are the types of combined oral contraceptives

•monophasic or multiphasic (biphasic, triphasic, or quadphasic), depending on whether dosage of hormones is constant or varies.

What are the 2 types of hormonal birth control?

•only progestin or combined progestin and estrogen.

Most infections following vaginal birth?

•polymicrobial, occur at the placental site, laceration or episiotomy; facilitated by rupture of membranes/ascent of bacteria. (vag. Delivery)

What is restrictive bariatric surgery?

•produce small stomach pouch.

Normal hormone levels?

•quickly return to prepregnancy state. Estrogen returns to prepregnant state w/in 1-2 weeks, progesterone w/in 48 hours. FSH and LH levels remain low for at least 2 weeks and rise gradually. These levels will be affected by frequency of breast feeding, therefore affecting ovulation and menstruation. Ovulation usually occurs at some point between days 45 and 94 postpartum in women who are NOT breastfeeding.

Spontaneous abortion is associated w/?

•related to embryo chromosomal abnormalities; signaled by uterine bleeding and cramping.

What if precancerous cervical lesions are found?

•removal of lesion by cryosurgery, laser ablation, loop electrosurgical excision procedure, or conization.

What contributes to cervical CA?

•risky sexual behavior, smoking, immunosuppression, oral contraceptives, high parity, genetic predisposition, nutritional status, diethylstilbestrol, infectious agents. Smoking -tobacco byproducts in bloodstream damages DNA in cervical cells. Theory is this damages body's ability to clear HPV infection Traces of tobacco found on cervix of smokers DES 40x more likely clear cell carcinoma of vagina or cervix (average age at diagnosis 19), DES removed from market 1971

PP eclampsia and preeclampsia?

•usually presents w/in 24-48 hours of delivery, however late preeclampsia can present after 48 hours, but before 4 months after delivery. - This can be new onset or a continuation of preeclampsia during pregnancy and the patient is at risk for pulmonary edema, renal dysfunction, eclampsia, thromboembolism, and stroke. •characterized by hypertension and proteinuria.

What is a mistimed pregnancy?

•woman wanted child in future, but not at present time.