OB Exam 2

Describe key urinary changes during pregnancy

-Blood flow to and through kidneys increases by 80%, GFR increases by 50% -More frequent urination during 1st and 3rd trimester -Small amounts of glucose and protein may be found in urine -Increased thirst b/c decreased release of ADH -More salt & water retained -Kidney stones may occ if fetus laying on kidney

Describe key respiratory changes during pregnancy

-Both O2 consumption and tidal volume (amount of air exchanged in a single respiration) increase, though tidal volume increases more -Mild hyperventilation & dyspnea may occur -> physiologic respiratory alkalosis -Diaphragm elevates -Ribs expand -Subcostal angle increases -Increased estrogen -> congestion of mucous membranes -Enlarged capillaries may lead to frequent nosebleeds (epistaxis)

Describe key cardiovascular changes during pregnancy

-Cardiac output increases by as much as 50% -Decreased peripheral vascular resistance -Total blood volume (PLASMA) increases by 40-50% while RBC production increases by 30%.. this leads to a hemodiluted state of physiologic anemia of pregnancy -Increase in fibrinogen & other clotting factors to prevent PPH (HOWEVER puts women at an increased risk for blood clots, which can lead to PE or stroke) -Temporary changes in heart sounds are common and benign

Describe key integumentary changes that occur during pregnancy

-Chloasma (darkened patches of pigmentation on face) -Blood vessels dilate and become more prominent and hair growth increases d/t increased estrogen -Palmar erythema d/t increased blood flow -Macules & nevi -Linea nigra (dark line from pubic symphysis to fundus) -Striae gravidarum -Nails may be brittle, hard, or soft

Describe common discomforts during pregnancy. What should we teach women to decrease these discomforts?

-Congestion & epistaxis (nose bleeds) -Orthostatic hypotension -Supine hypotension -Varicosities including hemorrhoids & varicose veins -Temporary carpal tunnel -Headache: can be common, but IS A SIGN OF PREECLAMPSIA & should be evaluated AT 20+ WEEKS -Vision changes: normal, but loss of vision, blurred vision, and double vision are ALL SIGNS OF PREECLAMSIA and should be evaluated -Breast tenderness -Increased vaginal discharge: normal, no douching, report foul odor, color change, bleeding -N/V -Ptyalism (increased saliva) -Heartburn -Constipation

Descrube key GI changes during pregnancy?

-Decreased peristalsis (d/t progesterone) -> heartburn, constipation, & gallstones -Softening of lower esophageal sphincter -Increased metabolic rate

How is mild preeclampsia managed?

-Delivery at 37 weeks -Assessment of maternal symptoms and fetal movement daily noting reduced fetal movement, vision changes, increased swelling, epigastric pain, shortness of breath, and headache -Check BP twice weekly -Weekly assessment of platelets and liver function tests

Describe key reproductive changes during pregnancy

-Hyperplasia & hypertony of uterine myometrial cells d/t estrogen release (uterus gets larger) -Between the 16th & 36th week the size of the uterus (in cm) from symphysis to fundus = gestational age -Braxton hicks -Increased vascularity of vulva, vagina, & cervix -pH of vagina slightly more acidic & prevents against bacterial pathogens -Operculum (mucus plug) forms in cervical canal to create barrier against pathogens

What complications are associated with PCOS?

-Irregular menstruation -Weight gain -Acne -Hirsutism -Increased testosterone -Increased hair growth -Ovulation

What problems during pregnancy require urgent assesment?

-Leakage of fluids from vagina -Vaginal bleeding -Decreased fetal activity -Headache that doesn't improve with acetaminophen (preeclampsia) -RUQ pain -Vision changes (may indicate preeclampsia) -Persistent contractions -New onset of lower back pain -Sensation of pelvic pressure -Menstrual like cramps -Dysuria

Dewcrie key musclulsketeal changes furing pregnancy

-Lordosis (increased L spine curvature) -Relaxin & progesterone increase mobility of the pelvis for delivery (also makes other joints less stable) -Round ligaments stretch -> pain -Diastasis recti (abdominal wall separation) -Increased calcium reabsorption d/t increased PTH secretion

What are some potential side effects of epidural & spinal anesthesia?

-Maternal hypotension -FHR changes -Increased uterine tone -Pursitis -Nausea & vomiting -Urinary retention & bladder distension -Respiratory depression -Lower extremity numbness & weakness -Headache -Back pain -Spinal cord injury -Maternal temperature -Increased risk of operative vaginal delivery

What testing should be done as a pregnancy progresses?

-Prenatal genetic risk assessment/ screening: 1-10wk -CVS (chorionic villi sampling): 10-12wk -Early amniocentesis: 12-15wk -MSAFP (alfofetal protein): 15-21wk (low levels indicative of down syndrome/ trisomy and high levels indicative of open neural tube defects)

Describe key endocrine changes during pregnancy

-Thyroid hormone increase (b/c mom supplies hormones to fetus until they can make their own at 12 weeks) -Insulin needs steadily increase beginning at in the SECOND half of pregnancy (20 weeks) as placenta increases production of HPL -Cortisol also increases during the second half of pregnancy (20 weeks) to promote lung and neuro development

How many veins and arteries are in the umbilical cord? What do they do?

1 Vein: Carries OXYGENATED blood from placenta TO fetus 2 Arteries: Carry DEOXYGENATED blood from fetus BACK to placenta to pick up more oxygen

Describe COC missed pill guidelines- 1 missed pill, 2 missed pills during week 1 or 2, 2 missed pills during week 3 or three missed pills

1 missed pill -Take 1 pill as soon as remembered 2 missed pills during 1st or 2nd week -Take 2 pills when remembered, and two pills the next day 2 missed pills during week 3 or 3 missed pills -Take one pill daily until Sunday, then throw out the remaining pack and start a new one

What are the three main functions of the placenta?

1. Circulation: delivers O2 and removes CO2 & wastes 2. Protection: transfers maternal immunoglobulins via passive immunity & prevents some viruses & toxins from entering fetal circulation 3. Hormone production (5 main hormones: HCG, HPL, Progesterone, Estradiol, and Relaxin)

Describe the three embryonic/fetal shunts.

1. Ductus venosus: allows blood to bypass liver 2. Foramen ovale: opening between right & left atrium, allows blood to bypass lungs 3. Ductus arteriosus: opening between aorta & pulmonary artery, allows blood to bypass lungs

Describe the path of embryonic fetal/blood flow

1. Spiral arterioles carry O2 to venous sinus 2. O2 diffuse across the venous sinus where it's picked up by capillaries of chorionic villi 3. Oxygenated blood travels up umbilical VEIN to inferior vena cava via ductus VEnosus, where oxygenated blood is mixed with DEoxygenated blood from the abdomen & lower extremities 4. Mix of oxygenated & deoxygenated blood enters right atrium... at this point two things can happen 4a. Blood travels through foramen ovale from the right atrium, into the left atrium where it ends up near pulmonary valve OR 4b. Blood travels through tricuspid valve to right ventricle, and then to the pulmonary valve 5. Blood is pumped from pulmonary valve into the pulmonary artery 6. Blood shunted between the pulmonary artery and the descending aorta via the ductus arteriosus 7. DEoxygenated blood leaves fetal embryonic circulation via umbilical ARTERIES which pick up blood from internal iliac arteries and return to placenta *NOTE that blood between the mom and the fetus is NOT actually mixing and the mom isn't ACTUALLY giving the baby blood, but is giving the baby oxygen (which are transported via blood)

Describe placental secretion of Progesterone

10 & 20wk peaks, decreases at the end of pregnancy so contractions can occur Functions to encourage breast development and relaxes uterus, preventing fetal rejection & contractions (also causes GI relaxation -> constipation)

When can fetal heart tones be heard with a doppler?

10-12 weeks

What is the expected fundal height at 12, 16, 20, and 36wks?

12 weeks: at pubic symphysis 16 weeks: halfway b/w pubic symphysis & umbilicus (16cm) 20 weeks: at umbilicus (20cm) 36 weeks: at xyphoid process (36cm)

Describe cervical screening and pap test frequency.

1st pap test done at 21 y/o. Pap test should be done every 3 years through age 29. Between age 25-29 HPV added for low grade pap test abnormality. Pap test done every 5 years though age 30-64. Women with no history of pap abnormalities no longer have to have pap tests after age 65.

At what gestational age is the anatomical ultrasound performed?

20 weeks

What is a normal blood glucose level for a newborn?

>50 mg/dL

What is macrosomia?

A high-birthweight infant, large for gestational age >4000 grams (8.8lb)

What is a blastocyst?

A rapidly dividing clump of cells that has inner (embryo) and outer (trophoblast) layers. Forms from morula 5-9 days after fertilization, & becomes an embryo once implantation occurs.

Describe the fetal nonstress test. When is it initiated? Describe the results.

Assess FHR reactivity to fetus' own movements; used to evaluate weather the fetus is receiving adequate blood flow and oxygen. Typically initiated around 26-28 wk Reactive nonstress test Weeks 26-32 Weeks 33+ Nonreactive nonstress test Above standards not met FHR should be monitored an additional 20-100 min Test repeated in 30 min or additional testing ordered Lack of reactivity may be d/t low O2, fetal sleep, fetal anomalies, maternal smoking, etc

What are the typical standing orders (assessment, precautions) for patients that preeclampsia is being "ruled out"?

Assessment Head-to-toe assessment q4 hrs HA -Visual changes (floaters or spots) -SOB/ breath sounds -Epigastric pain (RUQ) -Urine output -Edema -Deep tendon reflexes (patellar) q1 hr -Clonus VS q15 min Continuous pulse oximetry Fetal monitoring -Biophysical profile & amniotic fluid volume FHR and uterine contraction monitoring TID 24 hr urine sample Nonstress & contraction test Precautions Minimal stimuli ( to reduce risk for seizures)

What happens to the placenta at 20 weeks?

At 20 weeks, the placenta stops growing (technically it still thickens.. but it doesn't get any wider)

At what gestational age is the TDaP & RhoGAM administration?

At 27-36 weeks gestation for TDaP immunization (typically given at 27 weeks) At 28 weeks gestation for RhoGAM administration (for Rh- moms)

Where and how does the placenta attach?

Attaches at the decidua basalis with chorionic villi

Describe the autosomal dominant inheritance pattern. What diseases are autosomal dominant?

Autosomal dominant- only one parent needs to provide gene for it to be expressed Diseases: Huntington's & Rh factor If one parent is affected 50% will be affected, 50% will be unaffected

Describe the autosomal recessive inheritance pattern. What diseases are autosomal recessive?

Autosomal recessive- both parents must provide copies of the gene for it to be expressed Diseases: Cystic fibrosis, sickle cell anemia, and tay-sachs If both parents are carriers, 25% affected, 25% unaffected, 50% are carriers

What are the indications for early screening for preexisting type 2 diabetes in early pregnancy?

BMI >30 (obese) Diagnosis of gestational diabetes w/ previous pregnancy Diagnosis of impaired glucose metabolism (increased risk for diabetes) Diagnosis of PCOS

At what gestational age is the glucose tolerance test performed?

Between 24 and 28 weeks

What are the nutritional recommendations for diabetics in pregnancy? Describe caloric intake, nutrient distribution, and timing of calories.

Caloric intake BMI 18.5-30: 30cal/kg/d BMI >30: 22-25cal/kg/d Nutrient distribution 40% from carbs (complex carbs like fruits & veg preferred over baked goods) 40% from fat (avoiding trans fat) Timing of calories Breakfast- 10% of cal Lunch- 30% of cal Dinner- 30% of cal Snacks- 30% of cal

What effect do epidurals have on maternal BP? How do we prevent this effect?

Can -> hypotension d/t sympathetic blockade which causes relaxation of muscles and blood vessels. To prevent this, we need to give IV fluids (LR) before epidural placement (min- 500mL, max- 1000mL).

What is the first organ system to begin development during the embryonic system?

Cardiovascular system- tubular heart

What is constipation in pregnancy caused by? What education should we provide to patients?

Causes Decreased peristalsis due to increased PROGESTERONE Increased water absorption in colon Education Increase dietary fiber & fluids Light exercise

What is heartburn in pregnancy caused by? What education should we provide?

Causes Hormonal factors Decreased peristalsis Increased pressure from abdominal cavity Education Avoid fatty foods & excessive liquids with meals Avoid laying down after eating Avoid eating 3 hours before sleep

What are trophoblasts?

Cells forming the outer layer of the blastocyst... they'll become the placenta!

What labs are ordered for suspected preeclampsia?

Comprehensive metabolic panel Liver function test (LFT) CBC w/ platelets

Describe uses for ultrasound in the first trimester.

Confirm pregnancy Confirm viability (heartbeat present) R/O ectopic pregnancy Detect multiple pregnancies (twins, triplets?) Assess any vaginal bleeding Aid in chorionic villus sampling (12-14 weeks) Assess for nuchal translucency Assess for a maternal anatomical abnormality Estimate age of the pregnancy

What can we teach pregnant women to help them avoid hemorrhoids?

Constipation prevention measures Don't bear down Use of witch hazel pads, sitz baths, & topicals

What education related to exercise should we provide to pregnant women?

Continue exercise as tolerated (aerobic & strength training) Prevents insulin resistance of the mother & macrosomia of the fetus Stop exercising if experiencing... Regular painful contractions Leakage of copious fluid from vagina Vaginal bleeding Dizziness Headache Impaired balance Swelling Chest pain

Discuss DMPA. What is it? How often do women receive it? What are contraindications to DMPA? What nursing considerations should we keep in mind?

DMPA is the depo birth control shot. It is a progestin-only method of birth control. It's given every 3 months (q 10-16 wk) 4x per year. Contraindications Breast cancer Viral hepatitis Care considerations Return to fertility may take 18 mos Menstrual changes are common A pregnancy test should be performed prior to any injection performed 16 weeks or more after previous injection

What education related to travel safety should we provide to pregnant women?

Decreased ambulation -> increased risk of DVT, ambulate hourly Adjust seatbelt so it's over hips & not abdomen Pregnancy complications are most common during 1st and 3rd trimester, so the 2nd trimester is the best time to travel

Discuss the one hour glucose tolerance test and when it's done

Done between 24 and 28 weeks, assesses for gestational diabetes Patient drinks glucose solution & blood glucose tested an hour later. Blood glucose over 130 indicates need for further screening.

Describe risk factors for DVT during pregnancy & after birth

During pregnancy Diabetes BMI >30 Multiple gestation Varicose veins Maternal age >35 UTI Inflammatory bowel disease (UC or Chron's) Antepartum hospitalization After birth Cesarean delivery BMI >35 Delivery prior to 36 wk gestation Smoking Hemorrhage Infection Hypertensive disorders of pregnancy Diabetes Varicose veins UTI Cardiac disease Inflammatory bowel disease

What is endometritis? What major complication can it cause? How is it treated?

Endometritis is an infection of the endometrium. It is can cause late postpartum hemorrhage. It is treated using gentamycin & clindamycin.

There is direct mixing of maternal & fetal blood within the placenta. True or false?

FALSE! There is NO direct connection between fetal umbilical cord and maternal circulation. Fetus receives maternal O2 via diffusion!

True vs. False Labor

False labor: pain in abdomen, mostly irregular, resolve with rest & hydration True labor: active cervical change w/ regular contractions, pain felt in lower back w/ pressure in pelvis, rest or hydration do NOT resolve contractions

What are the blood glucose target levels in pregnancy for at home glucose monitoring?

Fasting: <90mg/dL Before lunch & before evening meal: <90mg/dL One hour postprandial (after 1st bite of meal): <120mg/dL

Describe physical changes of pregnancy during the first, second, and third trimesters.

First Fatigue Swollen, tender breasts Morning sickness (not just in the morning) Cravings or aversions to certain foods Moodiness Constipation More frequent urination Headaches Heartburn Weight gain or loss Second Aches & pains (esp. in pelvis, back hips, and thighs) Linea nigra (dark line running from pubic hair up to umbilicus, sometimes up to abdomen d/t estrogen; resolve after pregnancy) Darkening of nipples & areola Melasma (Hyperpigmented patches of skin esp. on face) Numbness or tingling of the hands and fingers Itchiness: palms, soles of feet, & abdomen Swelling: face, feet, and hands (late second trimester) Heartburn Third Heartburn SOB until "lightening" Swelling: ankles, feet, face Hemorrhoids Breast tenderness Colostrum (LIQUID GOLDDDD!!!) Sleep disturbance Contractions Baby "dropping" (2-4 wks before birth in 1st pregnancies & with labor with other pregnancies)

What are the newborn adaptations to extrauterine life? What occurs during each period?

First period of reactivity Lasts up to 30 min after birth HR of 160-180 bpm decreasing to 100-120 The newborn is less active and may sleep Period of decreased responsiveness Lasts 60-100 min The newborn is less active and may sleep Second period of reactivity Lasts 10 min to several hours The first bowel movement (meconium) likely to occur

Describe the routine prenatal visit schedule.

First visit occurs in the first trimester. Monthly visits through 27th week of pregnancy. Visits every other week from weeks 28 to 36. Weekly visit from 36 weeks- birth.

When do the 1st, 2nd, and 3rd trimesters occur?

First: wk 1-12 +6 Second: wk 13-26+6 Third: wk 27-end of pregnancy

Discuss proper breastfeeding latch.

Football & w/ "C" hold Clicking noise indicates that the baby is swallowing the milk

Gentamycin & clindamycin. What are they used to treat? What warning signs should we monitor for?

Gentamycin & clindamycin are used to treat endometritis. Warning signs for clindamycin: GI effects.. colitis Warning signs for gentamycin: ototoxicity, neurotoxicity

Describe placental secretion of Human Chorionic Gonadotropin (HCG)

HCG is secreted upon implantation by the corpus luteum, but production of HCG is taken over by the placenta at 10 weeks. HCG levels double every 48-72 hours and production peaks at 10 weeks. Decreasing levels of HCG usually indicate miscarriage. HCG is the source of nausea & vomiting during the first trimester. HCG functions to signal the corpus luteum to continue progesterone (also estrogen- but mainly progesterone) production to keep the uterine environment blood & nutrient rich

Describe placental secretion of Human Placental Lactogen (HPL)

HPL, AKA, HCS or Human Chorionic Somatotropin gradually increases throughout pregnancy. It has 2 functions. 1. Cue breasts to prepare for lactation 2. Acts on maternal metabolism by increasing insulin resistance of maternal cells leading to an increase in circulating glucose. This is essentially the body's way of giving glucose to the baby.

Describe signs of severe preeclampsia.

HTN: SYSTOLIC >160, DIASTOLIC >110 on 2 occ at least 4 h apart while pt at rest Thrombocytopenia (platelets <100,000/uL) Impaired liver function RUQ or epigastric pain New renal insufficiency (Cr >1.1 mg/dL or doubling of Cr) Pulmonary edema (fluid in lungs) New onset cerebral or visual disturbances

How do we assess DTRs? What is abnormal? What causes the abnormality?

Have pt bend knee at 90 degree angle and relax. Use bell/diaphragm portion of the stethoscope to test patellar reflex. Abnormal: Hyperreflexia (indicates worsening of preeclampsia) Cause: hyperstimulation of the CNS

Describe placental secretion of Relaxin

Highest during 1st trimester & the time of delivery Has 4 key functions 1. Prepares endometrium for implantation 2. Softens cervix at the end of pregnancy 3. Increases joint elasticity -> increased elasticity of pelvic joints (can also lead to increased risk for injury) 4. Assists with optimization of circulatory system Too much relaxin may lead to preterm birth due to inappropriate cervical softening

Name the main 5 hormones produced by the placenta.

Human Chorionic Gonadotropin: HCG Human Placental Lactogen: HPL (also called human chorionic somatotropin- HCS) Progesterone Estradiol (estrogen) Relaxin

Why would a pregnant woman receive RhoGAM? Why does she need it? When would it be given?

If a mother is Rh- and father is Rh+ there is the potential for the baby to be Rh+. If Rh- mom exposed to Rh+ blood sensitization can occur -> hemolysis of RBCs (which would terminate any future pregnancies), the fetus may experience hemolytic anemia. Rhogam given at 28 weeks to prevent Rh sensitization & within 72 hours after delivery if baby is Rh+.

Describe immediate nursing care for a patient with a suspected DVT or pulmonary embolism. How are pulmonary embolism & DVT treated?

Immediate nursing care Place pt in high fowlers position Maintain O2 sat >90% Administer anticoagulant, antianxiety, and analgesics as ordered Treatment Anticoagulant -Dalteparin (low molecular wt heparin; partial ANTIDOTE IS PROTAMINE; monitor for excessive bleeding & altered LOC) Antianxiety & analgesic -Morphine (opioid analgesic that decreases anxiety & dyspnea; should be diluted and administered IVP over 4-5 min)

How long after fertilization does implantation occur? What phase of the endometrial cycle dose it occur in?

Implantation of the blastocyst into the uterine wall occurs 6-10 days after fertilization. It occurs during the secretory phase of the endometrial cycle when progesterone increases blood flow & nutrients to the fetus.

Describe epidural anesthesia.

Includes local anesthetic or an opioid analgesic or both Injected into epidural space Preserves greater motor function than w/ spinal anesthesia Admin via indwelling cath, which allows multiple doses or continuous dose by pump

Describe spinal epidural anesthesia.

Includes local anesthetic, may be combined w/ an opioid analgesic Injected into subarachnoid space to mix w/ CSF Administered as single dose of med Lasts 1-3 hr

Describe combined-spinal epidural anesthesia.

Includes small amount of opioid w/ or w/o local anesthetic Injected into subarachnoid space then epidural cath is placed Allows superior motor ability than epidural or spinal anesthesia/ analgesia alone

How do the amnion and chorion compare in size?

Initially the chorion is larger, but later in the pregnancy the amnion expands more quickly until they both fuse to create the mature placenta (14 to 16 weeks)

Discuss maternal insulin needs during pregnancy.

Insulin needs steadily increase beginning at in the SECOND half of pregnancy (20 weeks) as placenta increases production of HPL. During the 1st trimester, hypoglycemia may occur & diabetic patients may need less insulin during this time. As the pregnancy progresses, the placenta gets larger and increases HPL production further leading to increased maternal insulin resistance. Women whose pancreas cannot keep up with increasing insulin demands develop gestational diabetes.

What are Braxton Hicks contractions? What education should we provide?

Irregular false contractions (usually abdominal area) w/ closed cervix (inactive cervical change). Educate women to come to hospital if contractions are felt in lower abdominal area, and if contractions don't stop with rest & hydration.

Describe signs of infant hypoglycemia

Jitteriness Irritability Poor feeding Weak, high pitched cry Tachypnea (>50 per min) Diaphoresis Pallor Lethargy Seizures Hypotonia

Discuss the composition of breast milk. Is any supplementation needed?

Lactogenesis I: Colostrum (starts in pregnancy, lasts through first few days after birth) -Rich in immunologic components -Epidermal growth factor -Laxative properties -Low in lactose, calcium, & potassium -High in magnesium, chloride, and sodium Lactogenesis II: Transitional milk (starts on day 2 or 3 and lasts 10 days) -Lactose increases -Immunologic components decrease -Fat and calories increase Lactogenesis III: Mature milk (about 2 weeks after birth) -Foremilk (more watery) & hindmilk (creamy w/ higher fat content) -20cal/oz -50% cal from fat -Provides complete nutrition aside from vitamin D Supplementation 400 IU Vitamin D q day

Where are heel-sticks performed?

Lateral surfaces of the posterior heel

What is magnesium sulfate used for in pregnancy? How is it given? What are s/sx magnesium toxicity? What's the treatment for magnesium toxicity?

Magnesium sulfate is a high risk drug used to prevent seizures & to promote fetal neuroprotection. It is given via IV (4-6g loading dose & 1-3g/hr maintenance dose) S/sx Toxicity Respiratory depression Oliguria (low urine output) Absent reflexes Lethargy Slurred speech Muscle weakness Loss of consciousness Treatment 1. Turn pump off 2. Administer ANTIDOTE CALCIUM GLUCONATE

What are the maternal, fetal, and childhood risks associated with obesity in pregnancy?

Maternal Gestational diabetes Gestational hypertension Preeclampsia C-section Would complications Fetal Neural tube defects Prematurity Still birth Congenital anomalies Macrosomia Low birth weight Childhood Childhood obesity HTN Increased mortality

What are the maternal & pregnancy related risk factors for preeclampsia?

Maternal risk factors Age <20 or >35 yeas African descent Decreases SES Family history 1st pregnancy or pregnant with new partner Type 1 or gestational diabetes Obesity Chronic HTN Kidney disease Thrombophilia (increased clotting tendency) Pregnancy related risk factors Chromosomal abnormalities Hederiform mole (molar pregnancy) Hydrops fetalis (ascites) Multifetal pregnancy Donated eggs or sperm Structural abnormalities

Metformin What is it & how does it work? What is it used for? Describe nursing considerations.

Metformin is an oral biguanide antidiabetic. It works by suppressing the production of glucose by the liver and increasing cell sensitivity to insulin (so that more less glucose is made by the body and more is transported INTO the cells by insulin) It is used to treat gestational diabetes. Should be d/c 48 hours before surgery & use of iodine contrast. Don't use with patients who have renal impairment. Increases risk for lactic acidosis

Describe s/sx ectopic pregnancy.

Most seen 6-8 weeks after LMP S/sx Vaginal bleeding Severe pain radiating from one side of abdomen Referred shoulder pain

What are the criteria for PCOS diagnosis?

Must have 2/3 of the following criteria for diagnosis -Oligo- or anovulation (no mensuration or <9 menstrual periods/ year) -Clinical or biochemical signs of hyperandrogenism (clinical signs: hirsutism, acne; biochemical signs: increased testosterone) -Polycystic ovaries: ovaries enlarged w/ many cysts

Does the amount of breast tissue a woman has determine her ability to breast feed? Why or why not?

NO! Amount of breast tissue or growth of breast tissue does not determine a woman's ability to breast feed. Breast milk is not stored, but made at the time the baby is sucking!

Is bed rest ordered for patients with preeclampsia? Why or why not?

No, bedrest is not ordered for patients with preeclampsia. Adverse effects of preeclampsia Physical -Weight loss -Muscle wasting & weakness -Bone demineralization and calcium loss -Decreased plasma volume & cardiac -Increased risk of blood clot0 -Cardiac deconditioning -Alteration in bowel function -Sleep disturbance and fatigue -Prolonged postpartum recovery Emotional: -Loss of control -Dysphoria: anxiety, depression, hostility, and anger -Guilt assoc. w/ difficulty in complying w/ activity restriction & inability to meet role responsibilities -Boredom & loneliness -Emotional lability (mood swings) -Financial strain assoc. w/ loss of income & tx. Cost Effects on Caregivers -Stress assoc. w/ increased responsibilities & disruption of family routine -Financial strain -Fear & anxiety for worrying on mommy and baby

Describe the pre-embryonic stage of pregnancy. Describe morula & blastocyst stages.

Occurs after fertilization & lasts about 2 weeks During the pre-embryonic stage, the fertilized ovum becomes a morula and then a blastocyst before entering the uterus. The morula is a group of 12-32 blastomere cells that are present 3-4 days after fertilization The morula begins to turn into a blastocyst when it enters into the uterus. The blastomere cells differentiate into inner and outer layers & the morula is NOW the blastocyst. The inner cell layers of the blastocyst become the embryo, and the outer cell layers of the blastocyst are called trophoblasts, and become the placenta. The pre-embryonic stage ends with implantation.

How can we teach pregnant women to avoid orthostatic and supine hypotension?

Orthostatic: rise slowly Supine: don't lay supine, left side lying is recommended

What is a pulmonary embolism? What are signs & symptoms of a pulmonary embolism?

PE is a blocked lung artery due to dislodged DVT clot Symptoms Dyspnea Pleuritic pain Cough Orthopnea (SOB when lying flat) Unilateral leg pain or swelling, redness, or tenderness Wheezing Hemoptysis (coughing up blood) Signs Tachypnea Tachycardia Course crackles Increased S2 heart sound JVD Fever

Where is oxytocin secreted from? What's its function?

PPP = Pitocin (oxytocin) produced from Posterior Pituitary Oxytocin plays roles in production of contraction, postpartum uterine contraction, and milk ejection

What can patients do to decrease back pain that occurs with lordosis due to pregnancy?

Pelvic tilt or rocking exercises

What is the treatment for group beta strep (GBS)?

Penicillin

Name the stages of pregnancy in order and when they occur.

Pre-embryonic: 1-13 days (technically ends with implantation) Embryonic: 2-8 +6 weeks (technically the embryonic stage begins once the amnion is formed) Fetal: 9 weeks-birth

Describe uses for ultrasound in the second & third trimesters.

Pregnancy dating ~ AKA EDD (less accurate as pregnancy progresses) Evaluation of fetal anomaly Evaluation of pregnancy finding on term-79exam that is abnormal from expected Assessment of amniotic fluid Assessment of the placenta location & grade In conjunction w/ procedures (e.g. amniocentesis, PUBS, version) Assessment of fetal well-being Assessment of vaginal bleeding Evaluation of cervical length

Name pregnancy related and maternal risk factors for postpartum hemorrhage (PPH)

Pregnancy related Uterine atony Retained placenta or membranes Subinvolution Failure to progress during second stage Adherent placenta Lacerations of vagina, vulva, & cervix Surgical/instrumental vaginal delivery Genital hematoma Large for gestational age infant Hypertensive disorders Use of oxytocin for induction Prolonged 1st or 2nd stage of labor Maternal History of PPH Maternal obesity Multiple previous births Precipitous labor (quick delivery) Uterine overdistension (from large for gestational age infant, or multiple gestations) Uterine infection Asian or Hispanic ethnicity Uterine inversion Coagulopathy (coagulation defect)

Why are pregnant women at an increased risk for DVT? What are signs & symptoms?

Pregnant women are at an increased risk for DVT d/t hypercoagulative state of body during pregnancy. This leads to increased clotting (the body is designed to dot this to prevent PPH after delivery). S/Sx Pain Warmth Swelling

What is a common OTC medication that pregnant women should absolutely not have and why?

Pregnant women should NOT have Ibuprofen (Advil or Motrin) as it can cause premature closure of the ductus arteriosus in the fetus (which leads to fetal pulmonary HTN & death)

How many additional calories should pregnant women add to their diet? What's the effect of too little or not enough weight gain?

Pregnant women should add.. -350 cal during 2nd trimester -450 cal during 3rd trimester Too little weight gain can lead to small for gestational age infants Too much weight gain can lead to preeclampsia, macrosomia, and increased risk for surgical delivery

What is methylergonovine maleate used for? What does it do? What should we check before administering? What are the contraindications? What are the risks?

Prevention and treatment of postpartum hemorrhage Stimulates smooth muscle contraction of uterus & vasoconstriction Assess BP before admin Contraindications IV admin HTN, hypertensive disorders associated with pregnancy Use prior to birth of fetus Risks Stroke HTN Tingling, cold, or numb digits Muscle weakness

What education should we provide to help pregnant women avoid ptyalism, as well as nausea and vomiting?

Ptyalism (increased saliva): suck on hard candy N/V: eat plain crackers before getting out of bed

How do we assess for clonus? What is abnormal? What causes the abnormality?

Rapidly dorsiflex the patient's foot, stretching the gastrocnemius muscle. Abnormal: Hyperreflexia (indicates worsening of preeclampsia) Cause: hyperstimulation of the CNS

What should pregnant women not consume? Why?

Raw or undercooked meat (d/t viruses, bacteria, & parasites) Hot dogs (unless steaming hot... may -> listeria) Lunch meat (unless steaming hot... may -> listeria) Unpasteurized dairy (may -> listeria) Large fish including shark and mackerel (d/t high mercury content) Raw sprouts (may contain foodborne bacteria) Alcohol (teratogen) Unpasteurized juice (may contain bacteria, especially e.coli) Tap water (tap water high in lead -> reduced birth weight, preterm delivery, & developmental delays) Caffeine (drinking more than 12oz/d can -> stillbirth, miscarriage, & reduced birth weight) BPA plastic (negative effect on fetal brain) Herbal teas or supplements (may lead to poor pregnancy outcomes)

What is the schedule and what are the elements of the postpartum assessment?

Schedule 1st hour- q 15 min 2nd hour- q 30 min 3-24 hours after- q 4 hours 24 hours after- q 8-12 hours (bp & pulse) *note that temp assesses q 4 hours for the first 8 hours after birth Elements Breasts Uterus Bowel & GI Bladder Lochia Episiotomy Homan's sign (DTR assessment) Edema Emotional

What education related to sexuality should we provide to pregnant women?

Sex is safe if there is no blood, rupture of membranes, and or evidence of preterm labor Sexual desire can increase or decrease Use protection against STI's Education r/t bodily changes (breast tenderness, etc.)

What are signs of maternal hypotension after epidural placement? What interventions should we employ in this situation?

Signs Decreased BP of 20% or more, or SBP of 100 mmHg or less Leads to decreased placental perfusion Drop in FHR > 120 bpm (fetal bradycardia) Reduction in FHR variability Nursing interventions Notify anesthesia provider and OB provider Position patient on her side (if not already) Administer oxygen by nonrebreather mask at 10-12 L/min Administer a vasopressor IV per orders & institutional protocol Elevate patient's legs Monitor BP & FHR every 2-5 min until mommy & baby stable Increased fluid administration (500-1000 mL)

What is a normal O2 sat for a fetus or infant before ductus arteriosus closure?

Somewhere in the 60% range

Describe placental secretion of Estradiol (estrogen)

Steady increase throughout pregnancy Functions to promote breast development, as well as promoting the strength of the myometrium (hyperplasia of myometrium)

What is the age of viability?

The age of viability is the gestational age at which a baby can survive outside the womb. There is no one specific age, as miracles DO happen, but at 23 weeks premature infants have a 23% chance of survival.

For how long should a mom breastfeed her newborn? How many times per day?

The baby should be breastfed until they're done- if they're still awake and the first breast isn't producing enough milk, switch to the other breast. The baby may feed 8 to 12 times a day.

What is the decidua?

The decidua is a name used to refer to the endometrium during pregnancy. A portion of the decidua is called the decidua basalis & forms the maternal part of the placenta.

What is a fetal pole? When can it be seen?

The earliest form of an embryo seen on ultrasound. Can be seen around 5-6 weeks.

Describe the embryonic stage. When does it occur? What are some major developmental milestones and when do they occur?

The embryonic stage begins once the amnion is formed & cell differentiation is complete. It begins around 2 weeks and lasts until 8 weeks + 6 days. Milestones Tubular heart begins beating & neural tube BEGINS fusion (wk 3) Respiratory & digestive tract begin formation & neural tube fusion COMPLETE (wk 4) Limb buds appear (wk 5) Fetal pole visible on ultrasound (wk 5-6) Heart formation complete (wk 6) 1st brain waves detectable (wk 8)

Describe the fetal stage. When does it occur? What are some major developmental milestones and when do they occur?

The fetal stage occurs from week 9 to birth. During the fetal stage, significant growth and development occur. Milestones 9-12wk: Fetal movement begins, kidneys begin to function, & genitalia differentiated 13-16wk: Oogenesis established in females, b.v. visible under skin, ridges that'll form fingers & toes are present 20wk: Fetal swallowing present, insulin production begins, lanugo & vernix caseousa cover the body 24wk: Lungs begin producing surfactant 28wk: Testes distend in males, fetus moves to head down position, blood produced in bone marrow 29-34wk: SubQ fat deposited, FHR variability more pronounced due to CNS maturity 33-38wk: Visual acuity 20/600, vernix caseousa visible in skin creases, lanugo only on back & shoulders Lungs & CNS continue to mature while fetus grows & gains weight

What does the first prenatal appointment include?

The first prenatal visit is the most in depth and includes -Screening & assessments (assess health history & EDD, meds or supplements being taken, psychological response to pregnancy, and assessment for genetic risk factors) -Labs (blood type & screen, STD testing: G/C, HIV) -Education (health promotion & s/sx to report)

What is the amnion?

The inner embryonic membrane, once it's formed- the embryonic stage is officially begun

What is the chorion? What does it arise from?

The outer embryonic membrane. Arises from trophoblasts. As chorion forms, fingerlike projections (chorionic villi) do as well. Over time the chorionic villi degenerate, EXCEPT for those beneath the embryo- they'll form the fetal portion of the placenta.

What does the placenta arise from? What does it do? What does the fetal side of the placenta arise from? What about the maternal side?

The placenta is formed by the maternal endometrium & fetal chorion. It exchanges fetal and maternal blood via capillaries of chorionic villi. Fetal side of placenta arises from chorionic villi and is lined by the amnion. The maternal side of the placenta arises from the decidua basalis.

What causes hypoglycemia in large newborns?

Throughout the pregnancy glucose passes from mother to fetus in utero via umbilical cord. Infant responds by making his/her own insulin. After birth, once the cord is clamped, infant is no longer receiving maternal glucose, yet insulin production continues in excess. Increased insulin with no glucose -> hypoglycemia

Why are thyroid hormones important for a growing fetus?

Thyroid hormones are critical to fetal neurological development

What lab tests are expected in a woman diagnosed with PCOS?

Thyroid panel : increased TSH (associated with HYPOthyroidism) would lead to increased menses, decreased TSH (associated with HYPERthyroidism) would lead to lighter menses or amenorrhea Testosterone: increased with PCOS -> hyperandrogenism DHEAS: Tests for adrenal sources of hyperandrogenism Serum Cortisol: to r/o Cushing's which can present similarly to PCOS Prolactin: To r/o pituitary tumor IGF-1: May indicate acromegaly Fasting lipids: Women with PCOS often have increased cholesterol 2hr oral glucose: Women with PCOS at increased likelihood to develop type 2 diabetes Fasting glucose or A1C: Assess for insulin resistance that may occ with comorbid type 2 diabetes

Describe recommended screenings throughout pregnancy an when they should be done.

Trisomy screening: 11-13 weeks Neural tube defects: 15-16 weeks Urinalysis: Done periodically throughout pregnancy to check for glucose and protein Second trimester ultrasound: 16-20 weeks One hour oral glucose test to screen for diabetes: 24-28 weeks Vaginal and rectal cultures to test for GBS: 35-37 weeks

What is WIC, what populations are served?

WIC helps individuals access adequate nutrition. It serves 3 populations: -Pregnant women -Postpartum women up to 6 months if not breast feeding, up to 1 year if mom breastfeeding -Children up to 5 years of age