Other Maternal Health Info

Cystic Fibrosis (CF) Testing

Autosomal Recessive disease that requires two mutant CFTR genes to cause disease ACOG recommends all women be offered testing to determine if offspring is at higher risk for CF. 1/3300 Caucasians have disease; 1/29 are carriers If woman +, father needs to be tested If father also +, risk of offspring having CF and recommendation of amniocentesis for genetic studies must be discussed with couple

Hormonal Contraceptives

Combination (estrogen and various types of progesterone) Methods -Pills -Must take a pill every day at the same time -28 day pill packs (Traditional: 21 days of active pills, 7 days placebo) There are also variable regimens Birth Control Patch -Patch is changed every week with one patchfree week -Common sites: back of shoulder, upper outer quadrant of buttocks, lower abdomen -NO extended or continuous use regimen Vaginal Ring -Ring is inserted into vagina for 3 weeks and removed for one week -Extended or continuous use regimen OK Progesterone-Only Methods -Pills -"The Shot" - Depo Provera (every 3 months) -Mirena/Liletta/Skyla - IUDs -Nexplanon- 1 implant system; effective for 3 years; available to providers who complete training Emergency Contraception -Plan B One Step- progesterone-only -ella- progesterone agonist/antagonist -Yuzpe Method- estrogen and progesterone -Paragard- IUD- NO hormone

If the results of the above screening tests or other factors indicate an increased risk for Trisomy 21, 13 or 18, what further diagnostic tests need to be performed to diagnose these diseases?

Detailed ultrasound examination; Cannot diagnose Trisomy 21, 13 and 18 Amniocentesis Chorionic villi sampling (CVS) If the results of the above screening tests do not indicate an increased risk for Trisomy 21, 13 and 18, it does not mean the baby is free of these conditions, nor does it mean the baby is free of all other possible defects, problems, or diseases.

Barrier Methods

Diaphragm -Patient needs to be fitted in office Femcap/Today Sponge Condoms -Block sperm from getting into the cervix -Failure rate: -Diaphram/Femcap/Today Sponge: 12.2-40% -Condoms: 13-21% Contraindications -Allergy to latex for certain methods, allergy to spermicide for certain methods, unable to place correctly

indication of high AFP, and Low estriol, hCG, and inhibin-A

Elevated levels of AFP indicate fetus may be at higher risk for neural tube defects, i.e. spina bifida and anencephaly Low levels of estriol, hCG, and inhibin-A indicate fetus may be at higher risk for chromosomal defects, Trisomy 21 and 18 and/or may be at higher risk for placental abnormalities

IUD

Foreign Body placed in uterus Paraguard - copper-T (non-hormonal) -Creates inflammatory response in uterus -Good for 12 years -Can be use for effective emergency contraception Mirena/Liletta/Skyla - levonorgesterel-releasing device -Progesterone thickens cervical mucus and causes anovulation in 15% women -Good for 3-5 years Failure rate: -Copper IUD - 0.6% (as good as BTL) -Hormonal IUDs - 0.1% (as good as vasectomy!) Absolute Contraindications -Pregnancy, acute pelvic infection

Fetal Fibronectin (fFN)

Glycoproteins found in plasma and produced during fetal life; is the "paste" that holds the membrane to the wall of the uterus Present in the maternal cervix in early pregnancy and usually 2-3 weeks prior to delivery If present in cervix late second trimester/early 3rd trimester, increased risk for PTL may be prese

ART

IVF-ET - in vitro fertilization-embryo transfer GIFT - gamete intrafallopian transfer ZIFT - zygote intrafallopian transfer Oocyte donation - eggs received from donor and inseminated in the lab; embryos transferred to prepared uterus Embryo adoption- embryo is donated and implanted into prepared uterus ICSI - intracytoplasmic sperm injection- one sperm is injected into egg TDI - therapeutic donor insemination Assisted hatching- zona pellucida is disrupted to improve implantation Gestational Carrier (surrogate mother)

Vibroacoustic Stimulation

If fetal baseline pattern is nonreactive for 5-10 minutes, a sound source such as laryngeal stimulator, is activated for 3 seconds on the maternal abdomen over the fetal head. Continue to monitor and assess 5 minutes after stimulation NST is considered reactive if there is an immediate and sustained increase in variability and accelerations If no response, test may be repeated at 1 minute intervals up to 3 times

Non-Stress Test (NST) - non-invasive evaluation of fetal response to natural contractile uterine activity or to an increase in fetal activity

Indications: maternal diabetes, late gestation, Rh sensitivity, IUGR, maternal complications, decreased or absent FM Interpretation of results: -Reactive NST: good -Non-reactive NST: bad!

Sterilization

Interruption in vas deferens or fallopian tube that prevents the sperm from meeting the egg Male - Vasectomy -Cut vas deferens through surgical procedure (in-office procedure) -Failure rate: 0.1% Female - Bilateral Tubal Ligation (BTL) -Cut fallopian tube through surgical procedure (outpatient surgery) -Failure rate: 0.6% Essure - non-surgical permanent birth control -Micro-inserts placed into fallopian tubes -Failure rate: 0.2% at 5 year follow-up All forms must be considered permanent and nonreversible Contraindications -Not 100% sure she wants NO MORE children; contraindications to surgery; against one's will -Informed consent is essential! -Pt must be 21 years old, received surgical consent, told method is considered irreversible, and information is in person's native language

Uterine or Endometrial Cancer

Most common cancer of the pelvic genital area; etiology unknown; slow-growing with good prognosis Affects women 50-65 y/o Risk factors: family history of uterine, ovarian, and/or colon cancers, older age, elevated levels of estrogen (i.e. unopposed estrogen, PCOS, obesity, late menopause), 2X greater incidence in whites than blacks, nulliparity

Nexplanon (the implant)

Progestin-only method that inhibits ovulation, alters cervical mucus, alters endometrial lining to prevent pregnancy Failure rate: 0.1% (statistically better than IUDs, sterilization, and other methods except abstinence) Good for 3 years Contraindications- pregnancy, allergy to etonorgesterel

Surgical infertility treatment

Removal of ovarian tumors, fibroids, adhesions in fallopian tubes or on ovary, or endometrial implants Repair tube damage Reconstructive surgery of structurally abnormal uterus Cervical surgery Repair varicele Reinastomosis of fallopian tube or vas deferens

quickening/fetal movement

20 weeks, should move 3 time within 1 hour for healthy wellbeing

Gonorrhea

2nd most commonly reported bacterial STD • Incubation: 2-7 days • Commonly asymptomatic • Can result in PID which increases risk for infertility and ectopic pregnancy • Treatment: Ceftriaxone and Doxcycline or Zithromax

Alpha Fetoprotein (AFP)/Maternal Serum Screening

AFP primarily screens for increase risk of neural tube defects (approximately 85% of babies with open neural tube defects will have an "increased risk" result) Hormone levels tested to improve identification of increased risk of certain chromosomal defects, i.e. Trisomy 21 and 18 Triple screening test AFP, estriol, hCG Quad or Tetra screening test AFP, estriol, hCG, inhibin-A

Infertility

Affects 10-15% of the population age- women >40 10-20% no known cause, 80% known.

Routine lab tests- First visit

Blood type, Rh factor, Antibody titers, CBC, pap, Hep B, RPR, CT, HIV, Rubella titer, UA, C&S

optional screening tests

CF, trisomy 21 and 18

GBS

Group B Strep (GBS) Culture ACOG recommends that all women have culture of the vagina and rectum performed at 35-37 weeks gestation. The purpose is to reduce GBS infection of the neonate Positive culture: prophylactic antibiotics during labor usually PCN - what if patient is allergic to PCN? Negative culture; no intervention

Lab tests at increased risk

Hep C, GC, TB

Contraction Stress Test (CST) or Oxytocin Challenge Test (OCT)

Invasive test to stimulate contractions for the purpose of assessing fetal response. Frequently conducted with a non-reactive NST. Negative OCT/CST: good Positive OCT/CST: bad!

Chlamydia

Most common reported bacterial STD with 3-5 million cases annually in US • Highest incidence in females ages 15-25 • Incubation: 1-2 weeks • Usually asymptomatic • Serious sequelae: PID, ectopic pregnancy and infertility • Treatment: Azithromycin or Doxycycline

1 hour GTT vs. 3 hr GTT

One hour 50 gm oral GTT Screening test to test the body's ability to use carbohydrates and risk for gestational diabetes Performed 24-28 weeks gestation Normal value <130-140 mg/dl Three hour 100 g oral GTT Diagnostic test performed if the one hour GTT is > 130- 140 mg/dl If two or more values out the four are met or elevated, patient has gestational diabetes and needs treatment Some health care providers will perform initially if patient has history of gestational diabetes with previous pregnancy

Ultrasound AP testing

Placental position and function Doppler blood flow AFI: 10-25 cm is normal Biophysical profile: assessment of fetus and its environment; 8-10 is fetal wellbeing. 0-2 is asphyxia

HIV/AIDS

S/S: may be asymptomatic for 10 years-fatigue, weight loss, swollen glands, diarrhea, and other nonspecific symptoms. Women may have persistent UTI's, vaginal yeast infections, and HPV and HSV outbreaks. • Screening: HIV antibody test (ELISA); if positive, must be confirmed with Western Blot test • Treatment - anti-retroviral medication • Prophylactic treatment may be offered, as indicated.

the "gold standard" for STD treatment

Sexually Transmitted Diseases Treatment Guidelines 2015

what are the oldest documented STDs?

Syphilis and Gonorrhea are the oldest documented diseases

Sequential integrated screening

This multiple marker screening can look for increased risk for Trisomy 21, 18, and neural tube defects. first and second trimester screening test

Nuchal Translucence (NT)

Ultrasonographic finding of an abnormal collection of fluid behind the fetal neck extending from the occiput to the upper posterior part of the spine. A measurement of >3-3.5mm between 11- 14 weeks gestation is considered abnormal and may indicate increased risk for Down Syndrome and/or heart defect

ultrasound

Use of high-frequency sound waves to create images The strength of the sending sound beam, the strength of the returning echo and the density of the object that the beam hits all create the image on a screen Two methods of ultrasound in Obstetrics -Abdominal -Transvaginal Ultrasound is used to assist in obstetric diagnoses and fetal surveillance.

Autosomal recessive inheritance

both genes of pair must be abnormal for disorder to be expressed, i.e. PKU; Sickle Cell Anemia; Cystic Fibrosis

Multifactorial Inheritance

conditions, traits, and/or diseases that involve a genetic component but are not caused by single gene or chromosomal defect; they are caused by combined effects of multiple genes (polygenic) and environmental factors. Examples may include: twins; congenital malformations (such as neural tube defects, cleft lip, pyloric stenosis, and congenital heart defects); HTN; coronary heart disease; diabetes; cancer; obesity; alzheimer disease; alcoholism; and psychiatric disorders)

X-linked recessive inheritance

hemizygous males and homozygous females are affected, i.e. color-blindness, hemophilia, and Duchenne Muscular Dystrophy

Causes of infertility

men: poor semen quality women: anovulation, obstruction of fallopian tubes, pelvic adhesions, endometriosis

Autosomal dominant inheritance

one copy of abnormal gene is needed for phenotype expression, i.e. Huntington Chorea; Dwarfism; Marfan Syndrome, Osteogenesis Imperfecta

X-linked dominant inheritance

one copy of mutated gene on the X chromosome is needed for phenotype expression, i.e. hypophosphatemia, Fragile X.

Predispositional testing-

positive result does not indicate the individual will develop symptoms, it indicates he/she is at higher risk of developing symptoms of that condition

3 levels of u/s

standard/basic: performed by ultrasound technicians and other health care providers with training. limited examination: performed for specific indications specialized/targeted: used in high risk pregnancies and performed by a highly skilled experienced technician and obstetrician or perinatologist

Mitochondria DNA inheritance

transmitted from mothers to all of their offspring through the cytoplasm of the egg, i.e. Kearns-Sayre syndrome and oncocytoma.

Presymptomatic testing-

with a positive result for a mutant gene, the individual will develop symptoms of that condition if he/she lives long enough

Herpes Simplex Virus (HSV)

• Caused by HSV-I and HSV-II • Estimated that 1 in 6 adults (ages 14-49)in the U.S. have HSV-II • Incubation: 2-12 days • S/S: primary outbreak- painful lesions that look like blisters, itching, dysuria, fever, swelling malaise; recurrent outbreaks usually not as bad. • Screening: serologic type-specific IgG-based assays - not recommended by CDC for routine screening • Diagnosis: PCR test and/or culture of lesion positive for HSV • Treatment: antiviral medication to decrease symptoms, does NOT CURE herpes virus. Acyclovir, Famciclovir, or Valacyclovir can be used for primary, recurrent or suppressive therapy

Syphilis

• Caused by Treponema pallidum • Highest incidence in 'men who have sex with men' • Incubation: 10 days-3 months • Stages: primary, secondary, latent, tertiary, neuro • Treatment: Penicillin G. or Doxycycline (depends on stage of disease

Trichomonas

• Caused by protozoan Trichomonas vaginalis • ~7.4 million new cases annually in US • Incubation: 4-20 days • S/S: none, diffuse, malodorous yellow-green vaginal discharge • Diagnostic Test: wet mount or Aptima PCR test • Treatment: Metronidazole and Tinidazole

Pelvic Inflammatory Disease

• Comprises inflammatory diseases in upper female tract: combination of endometritis, salphingitis, tubo-ovarian abscess, and pelvic peritonitis • Gonorrhea and Chlamydia usually involved • S/S: pain and tenderness in lower abdomen, fever, chills, nausea/vomiting, irregular bleeding • Treatment: 2 or more antibiotics

Human Papilloma Virus (HPV)

• Most common viral STD in US • ~50% of sexually active people have HPV infection (> 100 million cases) ▫ Types 6 and 11 are benign (cause genital warts). ▫ Types 16 & 18 and others linked with squamous cell cancers of genital tract and oropharynx (high risk HPV) • S/S: none, genital warts, abnormal pap • Screening - pap smear with high risk HPV DNA • Treatment: treat wart and abnormal cells, not virus • Prevention: HPV Vaccinations: best for girls and boys ages 11-12 - one for types 6, 11, 16, 18 and 5 other high risk types (Gardisil-9)

Hepatitis B (HBV)

• Sexual transmission among adults accounts for most HBV infections in the US • Incubation: 6 weeks-6 months • Screening: Hepatitis B surface antigen • Treatment: depends on acute or chronic infection • Prophylaxis: ▫ Begin post-exposure vaccination series ▫ Refer to health care provider or public health to begin or continue vaccination series