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Family Health Exam 1-2


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A woman who is pregnant
A woman who has had 2 or more pregnancies.
A woman who has completed 2 or more pregnancies to the stage of fetal viability.
A woman who has never been pregnant.
A woman who has not completed a pregnancy with fetus or fetuses who have reached the stage of viability.
The number of pregnancies in which the fetus or fetuses have reached viability, not the number of fetuses (e.g. twins) born. Whether the fetus is born alive or stillborn after viability is reached does not affect parity.
Postdate or postterm
A pregnancy that goes beyond 42 weeks of gestation.
A pregnancy that has reached 20 weeks of gestation but before completion of 37 weeks of gestation.
A woman who is pregnant for the first time.
1. A woman who is pregnant for the first time.
2. A woman who has given birth to only one child.
A pregnancy from beginning of week 38 of gestation to the end of week 42 of gestation.
The capacity to live outside the uterus; about 22 to 24 weeks since last menstrual period, or fetal weight greater than 500g.
Two-digit system

Ex: 1/0
Five-digit system

Gravida-Term-Preterm births-Abortions/miscarriages-Living children
Four-digit system

It drops the G from the five-digit system
When does the production of hCG begin?
As early as the day of implantation and can be detected in the blood as early as 6-11 days after conception or about 20 days since the last menstrual period (LMP) and in urine about 26 days after conception (should be the first void of the day which results in the highest level of hCG).
When does hCG peak?
After about 60-70 days of pregnancy and then begins to decline.
When is the lowest level of hCG reached?
At about 140 days of pregnancy.
What is the abbreviation for the last menstrual period?
What are the different types of pregnancy tests?
- Immunoassay
- Radioimmunoassay
- Radioreceptor assay
- Enzyme-linked immunbsorbant assay (ELISA)
What type of test is the basis for home pregnancy tests?
Agglutination inhibition test which depends on an antigen-antibody reaction between hCG and antiserum. A urine test which is accurate 4-10 days after conception, but best used after 6 weeks gestation.
RIA (beta subunit of hCG serum or urine). Accurate with low hCG levels and can confirm pregnancy 1 week after conception.
(RRA) is a serum test that measures the ability of a blood sample to inhibit the binding of radio labeled hCG receptors. The test is 90-95% accurate from 6-8 days after conception.
What is the most common mistake made with a home pregnancy test?
Doing the test too early.
How do medications affect pregnancy tests?
Tranquilizers and anticonvulsant medications can cause false positive results.

Diuretics and promethazine can cause false negatives.
When does the uterus enlarge and why?
After the third month the uterus enlarges due to the mechanical pressure of the growing feature.
What is the shape of the uterus prior to conception, during the second trimester, and later as the fetus lengthens?
Upside down pear, then spherical and globular, and finally ovoid.
12-14 weeks, where can the fetus be palpated?
Above the synphysis pubis.
At 22-24 weeks, where can the fetus be palpated?
At the level of the umbilicus.
At full term where can the fetus be palpated?
At the xiphoid process.
What is lightning?
Between 38-40 weeks the fetus begins to descend and engage in the pelvis. This may occur in nullipara, approximately 2 weeks prior to the onset of labor and at the start of a multiple labor.
What is commonly used to estimate the the duration of pregnancy?
Fundal height. There are variations depending on the amount of amniotic fluid, presence of more than one fetus, obesity, and even a variation depending on the examiner.
What type of contractions can be felt during the fourth month?
Uterine contactions can be felt through the uterine wall. This is commonly called Braxton-Hicks contractions, which are painless contractions that occur intermittenly throughout the pregnancy.
What is the purpose of Braxton-Hicks contractions?
They facilitate uterine blood flow through the intervillous spaces of the placenta and promote oxygen delivery to the fetus.
What does uteroplacental blood flow depend on?
Depends on the maternal blood flow to the uterus. It increases rapidly as the uterus increases in size (20X). The fetoplacental unit grows even more rapidly.
What is the maternal blood volume during a normal pregnancy? (in mL)
1/6 of the total maternal blood volume is within the uterine vascular system. 500mL per minute.
3 factors that decreases uterine blood flow.
- Low mean arterial pressure
- Contraction of the uterus
- Maternal position
What may increase uterine blood flow?
Estrogen stimulation
What may be used to measure uterine blood flow in pregnancies that may be at risk?
A doppler ultrasound.
Conditions that are considered at risk associated with decreased placental perfusion
- Hypertension
- Intrauterine growth restriction (IUGR)
- Diabetes Mellitus
- Multiple gestation
What keeps the uterus midline?
The round ligaments.
Passive movement of the unengaged fetus and can be identified generally between the 16th and 18th week. Done through a vaginal exam. Bounce it away and it will float back and examiner will feel a tap. Probable objective sign of pregnancy.
First recognition of fetal movement. Feeling life. Multiparas woman may feel it at 16 weeks. Nulliparous may not notice these feelings until the 18th week. Presumptive sign of pregnancy.
Chadwick's Signs
Pregnancy hormones prepare the vagina for stretching during childbirth by causing the vaginal mucosa to thicken, connective tissue to loosen, smooth muscle to hypertrophy and the vaginal vault to lengthen. Increase vascularity causes a violet - blue coloring of the vaginal mucosa = Chadwick's. 6-8th week. Probable sign of pregnancy.
White or slightly gray mucoid discharge. Response to cervical stimulation by estrogen and progesterone. The fluid is whitish due to the presence of many exfoliated epithelia cells normal in pregnancy.
Why is the pH more acidic during pregnancy?
This is a result of increased production of lactic acid caused by Lactobacilus acidophilis. Acting on the glycogen in the vaginal epithelium.
Montgomery's tubercles
Enlargement of the sebaceous glands embedded in the primary areola, purpose is as a protective role to keep the nipple lubricated for breast feeding.
When is the development of mammary glands complete?
When isn't there a lack of lactation?
Until there is a drop in the level of estrogen which occurs after birth.
How much does blood volume increase during pregnancy?
By approximately 1500mL
What maintains a normal b/p despite the increase in volume?
Peripheral vasodilation
Physiologic anemia
Since the increase in plasma volume is disproportionately greater than the increase in red cell mass, a physiologic dilution occurs, which normally results in an absolute drop of 3 to 5 percent in the hematocrit value. During the last trimester of pregnancy, the rate of increase in plasma volume reaches a plateau, but the red cell mass continues to rise, resulting in a slight increase in the hematocrit.
Pulmonary fx changes
Increase in tidal volume. These changes are r/t the elevation of the diaphragm and the chest wall changes.
What are changes to the skin related to in pregnancy?
hormone changes and mechanical stretching.
What are some general changes that happen to the skin during pregnancy?
- Increases skin thickness
- Subdermal fat
- hyperpigmentation
- Increased hair and nail growth
- accelerated sweat and sebaceous gland activity
- Increased circulation and vasomotor activity
What causes hyperpigmentation?
stimulated by the increase of the anterior pituitary hormone melantropin.
Chloasma or facial melasma
AKA the mask of pregnancy. Blotchy/brownish hyperpigmentation of the skin over the nose and forehead, esp. in woman with dark complexions. Happens to 50-70% of women; after 16 weeks gestation.
Linea nigra
Pigmented line extending from the symphysis pubis to the top of the fundus. It's known as the linea alba before hormone pigmentation.
Striae gravidarum
(stretch marks) Occurs on the lower abdomen; 50-90% of women get them; may be caused by the action of adrenocorticosteroids. Tend to occur over the areas of maximum stretch (abdomen, thighs, and breasts)
Striae definition
separation within the underlying connective tissue of the skin.
(vascular spiders) Tiny star-shaped or branched, slightly raised and pulsating end-arterioles usually found on the neck, thorax, face, and arms.
Palmer erythema
Pinkish red, diffusely mottled or well-defined blotches seen over the palmer surfaces of the hands in 60% of white women and 35% of women with dark skin.
gingival granuloma gravidarum
excessive hair growth in unusual places.
What does increased estrogen cause?
exaggerated elasticity and softening of the connective and collagen tissue.
an ovarian hormone that assists with relaxation and softening.
Numbness and tingling of the hands.
What is reponsible for intitial lactation?
Serum prolactin from the anterior pituitary.
What stimulates uterine contractions and stimulates the letdown or milk ejection reflex?
Oxytocin from the posterior pituitary.
Placental hormones plus somatomammotropin
Acts as a growth hormone, contributes to breast development, decreases maternal metabolism of glucose, increases the amount of fatty acids for metabolic needs.
Thyroid (thyroxine)
Possibly plays a role in early neural development of the fetus.
controls calcium and magnesium metabolism
Why is preconception care important?
- It helps women avoid unintended pregnancy
- It promotes the health of women and children
- It's important for women who have had repeated miscarriages
- Helps women identify key activities to avoid poor birth and infant outcome
What is assessed during preconception care?
1. Nutritional status and folic acid intake
2. Exposure to environmental toxins and teratogens
3. Genetic background
4. Substance use
5. Medical conditions and current meds
6. Infectious disease and vaccinations
7. Psychosocial concerns
What's the leading causes of maternal death?
- hypertensive disorder
- infection
- hemorrhage
What factors relate to maternal death?
- age
- lack of prenatal care
- low education
- unmarried status
- nonwhite race
Maternal Death definition
The death of a woman while pregnant or within 42 days of a termination of a pregnancy irrespective of duration and site of pregnancy from any cause related to or aggravated by the pregnancy or its management but not by accidental or incidental causes.
4 types of risk factors for women
- Biophysical
- psychosocial
- sociodemographic
- environmental
Types of antepartum testing
- serum testing
- daily fetal movement count
- ultrasound
What does serum testing look at?
- AFP (alpha-fetoprotein): produced by the liver, can be detected at 14-34 weeks gestation
- Daily fetal movement count: 2X/day, count the number of kicks over an hour
- Ultrasound:
How can an ultrasound be administered?
abdominally or transvaginally
Abdominal Ultrasound. Should the bladder be full or empty?
useful after the first trimester, the bladder must be full.
Transvaginal Ultrasound. Should the bladder be full or empty?
good for obese patients, good for first trimester, bladder must be empty.
What is AFI?
Amniotic fluid volume
What's a normal AFI?
What does a doppler-flow look at? What are concerns?
The blood flow between the fetus and the placenta. Hypertension and IUGR are area of concern.
fetal heart rate
What is an accurate predictor for fetal death?
Why is an amniocentesis performed?
- genetic concerns
- fetal maturity
- fetal hemolytic disease
- meconium
Electronic fetal monitoring
Monitors fetal heart rate in relation to uterine activity.
Variability indicates intact fetal nervous system pathways.
Non-stress Test (NST)
- Non-invasive, takes approx. 20 minutes
- Fetus produces characteristic FHR patterns (accelerations) in response to fetal movements
- Absence of accelerations usually indicates fetal sleep cycle.
NST Interpretation
1. Reactive: 2 or more accels lasting 15 seconds, 15 beats above baseline
2. Nonreactive: No accels or accels <15 seconds, <15 beats above baseline
3. Unsatisfactory: Quality of FHR recording not adequate for interpretation
Contraction stress test
- oxytocin stimulation occurs to create contractions
- provides an early warning of fetal compromise
- if no late decelerations (bad) are observed then the CST is considered negative
- beware of hyperstimulation
How long is a pregnancy?
It spans 9 months; 10 lunar months of 28 days (280 days total).
How is the pregnancy time broken down?
Into trimesters:
First: weeks 1 - 13
Second: weeks 14 - 26
Third: weeks 27 - 40
Nagele's Rule for calculating the date of birth
1. Determine the first day of LMP
2. Subtract 3 months
3. Add 7 days, and adjust year as necessary.

*Assumes a 28 day cycle.
Presumptive indicators of pregnancy
- *missed menstrual period
- home pregnancy test positive
- * amenorrhea, nausea, vomiting, breast tenderness, urinary frequency, fatigue, morning sickness
- quickening (perception of fetal movement)
Probable indicators of pregnancy
(felt by a doctor or nurse)
- uterine enlargement
- braxton hicks contractions
- uterine souffle (the sounds/murmurs heard with a stethoscope over the uterus. If pregnant it will coincide with the pulse)
- ballottement (a former maneuver used to check a pregnancy by pushing up the head or breech of a fetus by fingers inserted into the vagina, so as to cause the floating fetus to rise and fall again like a heavy body in water)
- positive pregnancy test
Positive indicators of pregnancy
- presence of a fetal heartbeat distinct from the mother's.
- Visualization (e.g., ultrasound)
Prenatal care
- identifies existing risk factors and other deviations
- emphasis on preventive care & optimal self-care
- sought routinely by women of middle or high socioeconomic status
- there are barriers to poorer women
- it should be multidisciplinary and holistic
Initial visit
- gather info
- make approp. referral (WIC, ultrasound, blood work, parenting skills class)
- observe woman's affect, emotional status
- provide teaching r/t pregnancy as needed
What is done during a physical assessment?
- *blood pressure*, pulse, resp, temp.
- urine specimen collection (protein and sugar)
- fundal height
- symptoms of an STI
How is fundal height/weeks determined?
weeks = cm
Supine Hypotension
- occurs when a pregnant woman lies flat on her back
- weight of abdominal contents can compress the vena cava and aorta
- this causes a drop in b/p and feeling of faintness
- intervention: place woman in side-lying position
Important Maternity Labs
- hemoglobin/hematocrit
- blood type/Rh factor
- rubella titer
- TB test
- Urinalysis
- Pap test, smears for STIs, screen for GBS
- glucose tolerance
- Toxoplasmosis
- Other: gonorrhea, syphilis, varicella, hepatitis B, HIV
- Rubella
- Cytomegalovirus
- Herpes simplex virus
Fetal Assessment
- Fetal HR can be heard at the end of the first trimester
- fundal height measurement: usually by 18-30 weeks gestation the fundal height equals the weeks gestation
- Lab tests: mult. marker or triple-screen (serum testing) blood test, other blood tests (RPR/VDRL, CBC, anti-Rh)
- Ultrasonography
- amniocentisis
Education for self-care
- nutrition
- personal hygiene
- prevention of UTIs
- Kegel exercises
- Preparation for breastfeeding newborn
- dental health (due to morning sickness)
- physical activity
- posture and body mechanics
- R&R
- Employment & travel
- clothing
- meds
- Immunizations (no live cultures, no rubella)
- alcohol, smokes, and others
- caffeine
- normal discomforts
Normal Discomforts: First trimester
breast/changes growth, fatigue, nausea, vomiting, increased urination, ptyalism (increased salivation)
Normal Discomforts: Second trimester
pigmentation, pruritis (itching), supine hypotension, food cravings, heartburn, constipation, flatulence, head aches
Normal Discomforts: Third trimester
SOB, increased urination freq returns, perineal discomfort, leg cramps, ankle edema
Potential Complications: Preterm Labor
- subtle, may not know it's happening
- teach patient to feel fundus for contraction
- encourage patient to empty bladder and force fluids (checks hydration status)
- if ctx are q 10 minutes or more frequent for an hour or bloody show present, call provider
Sexuality During Pregnancy
- sex is OK
- risk/caution w/ high-risk pregnancy with coitus and orgasm
- masturbation, touching, oral sex may be alt.
- safer sex
Age: Adolescents
Less likely to receive adequate prenatal care. delay in receiving care, don't gain enough weight, baby at risk for LBW, disability, and death
Age: Older than 35
Delayed fertility or desired additional child, more educated, accessibility to resources, increased risk for LBW, premature birth, IUGR, abruptio placenta.
What is IUGR?
Intrauterine growth restriction (IUGR) is a term used to describe a condition in which the fetus is smaller than expected for the number of weeks of pregnancy. Another term for IUGR is fetal growth restriction. Newborn babies with IUGR are often described as small for gestational age (SGA).
What is abruptio placenta?
Abruptio placentae (ie, placental abruption) refers to separation of the normally located placenta after the 20th week of gestation and prior to birth.
What is placenta previa?
pregnancy in which the placenta is implanted in the lower part of the uterus (instead of the upper part); can cause bleeding late in pregnancy; delivery by cesarean section may be necessary.
What is Preeclampsia?
Preeclampsia, also known as toxemia, is a complex disorder that affects about 5 to 8 percent of pregnant women. You're diagnosed with preeclampsia if you have high blood pressure and protein in your urine after 20 weeks of pregnancy. The condition most commonly shows up after you've reached 37 weeks, but it can develop any time in the second half of pregnancy, as well as during labor or even after delivery (usually in the first 24 to 48 hours).
What can occur in multi-fetal Pregnancies?
- high risk
- anemia, placenta previs, and preeclampsia are more common
- often ends prematurely
- more than 3 fetuses may require/counsel on a reduction
What can cause severe backache in a multi-fetal pregnancy?
uterine distention
Birth support people. The focus is on the woman.
What is a cholecystectomy?
The surgery to remove the gallbladder.
What does Orthoclone OKT3 do?
It is used to reduce the body's natural immunity in patients who receive organ (for example, kidney) transplants.

When a patient receives an organ transplant, the body's white blood cells will try to get rid of (reject) the transplanted organ. Muromonab-CD3 works by preventing the white blood cells from doing this.
What does the drug Methergine cause?
Causes increased b/p.
When does implantation occur?
after 6 days
When can abruptio placenta occur?
After week 20.
During what weeks do Chadwick's signs occur?
During the 6-8th week.
What is a Maternal Serum Screen (the other names are Bart’s test, Triple screen, Maternal Serum Test)?
It evaluates your risk of having a baby with chromosome abnormality or neural tube defect.
What is uterine souffle?
A blowing sound, synchronous with the cardiac systole of the mother, heard on auscultation over the pregnant uterus. Also called placental souffle.

What is the most crucial time for embryonic and fetal development?
The first trimester.

What nutrient is the most crucial for the developing fetus? What is the recommended amount for intake?
Folic acid. It prevents NTD. 400 mcg/day is recommended for all women of reproductive age.

What does good nutrition prevent?
LBW and preterm infants.

What does the Pregnancy Nutrition Surveillance System (PNSS) do?
It identifies and reduces pregnancy-related health risks.

How much weight should the mother gain during the first trimester?
1 - 2.5 kg

How much weight should the mother gain during the second and third trimester?
0.4kg per week.

Who is at risk for SGA (small for gestational age)?
A woman who's weight gain in early pregnancy is poor.

What are the BMI categories and their ranges?
Underweight = <18.5
Normal weight = 18.5 - 24.9
Overweight = 25 - 29.9
Obesity = BMI of 30 and up

How is BMI calculated?
BMI = wgt in kg/hgt in meters squared

What are obese women at greater risk for?
- Macrosomia, fetopelvic disproportion,c-section, post-partum hemorrhage, UTI, birth trauma, and late fetal death
- gestational diabetes and preeclampsia
- 2 times risk for congenital defects

How much weight should be gained during pregnancy?
Underweight women: 12.5-18kg
Normal BMI women: 11.5-16kg
Overweight women: 7-11.5kg

How many calories does a non-pregnant woman need?

How many calories does a pregnant (2nd & 3rd trimester) woman need?
an extra 300 calories/day

How many calories does a lactating woman need?
an extra 500 calories/day

What nutritional element is basic to human growth?

How many fluids/day is recommended during pregnancy?
1500-2000 mL/day

What does dehydration increase the risk for?
cramping, contractions, preterm labor.

Who should avoid aspartame?
mom's with PKU

How is iron best absorbed?
With OJ and on an empty stomach.

What is a common side effect of iron supplementation?

How can nausea/vomiting be managed during the first trimester?
- eat dry starchy food in am
- small frequent meals
- drink your fluids between meals
- decrease intake of fried foods
- drink tart drinks (can be helpful)
- ginger root can help reduce nausea

Indicators of nutritional risk in pregnancy
- adolescence
- frequent pregnancies: 3 within 2 yr period
- poverty
- poor diet habits
- use of tobacco, alcohol, drugs
- being over/under with weight
- low HCT or HGB

Pregnancy complications related to nutrition include what?
- anemia
- preeclampsia
- gestational diabetes

What is gestational diabetes (GDM)?
It is either type 1 or type 2 existing before pregnancy; it's any degree of glucose intolerance with onset or recognition during pregnancy.

What are some preexisting conditions that would need to be addressed before conception/delivery?
- diabetes
- cardiovascular disease
- epilepsy
- Substance abuse

What is the pathogenesis of diabetes mellitus?
A group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.

Diabetes may be caused by either...
- impaired insulin secretion
- inadequate insulin action in target tissues.

What are the risk factors for gestational diabetes?
- age greater than 30
- family history of type 2 diabetes
- obstetric history of an infant weighing more than 9 lbs
- hydramnios
- unexplained stillbirth
- miscarriage
- glucosuria on 2 consecutive prenatal visits

glucose in the urine

a condition during pregnancy characterized by too much amniotic fluid. It is also known as amniotic fluid disorder or polyhydramnios

What are offspring of gestational diabetes mothers at risk for?
obesity and diabetes

What do almost all women with pre-gestational diabetes require during pregnancy?

What happens to the oral hypoglycemic agents used by type 2 diabetics during pregnancy?
They are discontinued.

What type of diabetic is prone to hypoglycemia during pregnancy?
Type 1

What is the primary energy source used by the fetus?

During the first trimester what stimulates increased insulin production?
Increased progesterone and estrogen levels.

What happens to insulin levels during the 2nd and 3rd trimesters?
Insulin requirements will increase as there is an increase in glucose tolerance.

Diabetic Ketonacidosis
caused by inadequate insulin treatment leading to increased levels of ketones. These acidic chemicals in the blood are the product of breaking down fat for energy, the only choice your body has if there is inadequate insulin over a period of time. High levels of these ketones alter the chemistry of your body and endanger your health and that of your baby.

Maternal Risks/Complications: Diabetes
- poor glycemic control pre-conception increases the patient's risk for miscarriage
- macrosomia occurs in 25-45% of diabetic pregnancies
- increased risk for infection
- diabetic ketoacidosis (DKA) occurs most often during the 2nd and 3rd trimesters

What does macrosomia increase the risk for during labor?
shoulder dystocin

What are fetal & neonatal risks/complications?
- macrosomia
- hypoglycemia
- respiratory distress syndrome
- congenital defects: cardiac, CNS, & skeletal
- Polycthemia (increased blood viscosity)
- hyperbilirubinemia

What is hyperbilirubinemia? And at what level does bilirubin have to be above to be considered this?
A total serum bilirubin level above 5 mg per dL. Jaundice typically results from the deposition of unconjugated bilirubin pigment in the skin and mucus membranes.

What should a newborn's glucose be?
40-60 mg/dL

Target blood glucose levels for pregnancy
Fasting: 60-90
Pre-meal: 60-105
Bedtime: 90-120

Postpartum Diabetic Patient
- insulin requirements sunstantially decrease
- monitor type 1 glucose: give insulin if BG is greater than 200mg/dl
- gestational diabetic does not need insulin
- encourage breastfeeding
- watch for s/s of infection

Cardiovasular Disease & pregnancy
- normal heart compensates for increased workload
- degree of disability often more important in treatment and prognosis
- miscarriages increase
- preterm labor and birth more prevalent

Major cardiovascular changes during pregnancy that affect women with cardiac disease are...
- increased intravascular volume
- decreased systemic vascular resistance
- cardiac output changes during labor & birth
- intravascular volume changes that occur just after childbirth

What classifications of meds could patients be on for cardiovascular disorders?
Classes A, B, C, or X.

What is Eisenmenger's syndrome?
This is a serious condition in which a right-to-left movement of blood occurs, resulting in unoxygenated blood coming into the left side of your heart and being pumped into the general circulation. Without oxygenated blood going to your uterus, the placenta and baby can die.

CVD: Plan of Care
- restricted activities, increase rest 8-10 hours of sleep per day
- bed rest
- nutritional counseling
- anticoagulant therapy: heparin is the drug of choice (no coumadin)
- decrease stress in general

What are the risks associated with a pregnant woman with epilepsy?
- effects can be unpredictable
- more at risk for seizures
- can coexist with ecclampsia
- increased risk for vaginal bleeding
- increased risk for placental abruptio

Anemia during pregnancy
- affects 20% of all pregnancies; iron deficiency is most common
- iron deficient women should increase elemental iron to 60-120 mg/day
- anemic women at increased risk for hemorrhage after delivery and may need to be transfused

What are women using anti-epileptic drugs (AEDs) at risk for?
- cleft lip/palate
- cogential heart disease
- urogenital defects
- neural tube defects

Why is folic acid so important to patients using AEDs?
AEDs have a folic acid wasting effect.

HIV Pregnancy Risks
- these women are the fastest growing population of individuals with HIV infection and AIDS
- 78% of HIV infected women are African-American or Hispanic
- perinatal transmission: 90% of all pediatric cases are due to transmission of the virus from mother to child

What are all HIV+ women treated with during pregnancy?
- Zidovudine (AZT)
- They should also use condoms during pregnancy

HIV: Intrapartum Care
-IV AZT; loading dose upon admission, maintenance dose during labor
- delay rupture of membranes
- avoid FSE and scalp pH sampling
- wipe baby clean, usually early bath
- avoid breastfeeding
- monitor postpartum mom for infection

What is FSE?
Fetal scalp electrode

Substance abuse: barriers to treatment
- women fear losing custody of child and criminal prosecution
- substance-abuse treatment programs do not address issues affecting pregnant women
- long waiting lists and lack of health insurance present further barriers to treatment

Smoking risks during pregnancy
- bleeding complications
- miscarriage
- stillbirth
- prematurity
- placenta previa
- placental abruption
Cystoscopy allows your doctor to look at areas of your bladder and urethra that usually do not show up well on X-rays. Tiny surgical instruments can be advanced through the cystoscope that allow your doctor to remove samples of tissue (biopsy) or samples of urine from each kidney.
a surgical procedure by which the internal structure of a joint is examined for diagnosis and/or treatment using a tube-like viewing instrument called an arthroscope.
a procedure that allows a health care provider to look directly at the contents of a patient's abdomen or pelvis, including the fallopian tubes, ovaries, uterus, small bowel, large bowel, appendix, liver, and gallbladder.
a procedure in which a surgeon fastens an undescended testicle inside the scrotum, usually with absorbable sutures. It is done most often in male infants or very young children to correct cryptorchidism, which is the medical term for undescended testicles.

What are some examples of gestational conditions?
- hypertension
- hyperemesis gravidarum
- hemorrhagic complications
- ectopic pregnancies

What are the most common medical conditions reported during pregnancy?
hypertensive disorders

What race is more likely to die from preeclampsia?
African-American Women

What are the classifications of hypertensive states?
- gestational hypertension
- transient hypertension
- preeclampsia
- eclampsia
- chronic hypertension
- preeclampsia superimposed on chronic hypertension

What is Gestational HTN?
The onset of HTN during pregnancy (after week 20 usually) where there is no proteinuria.

What is transient hypertension?
Gestational hypertension with no signs of preeclampsia present at the time of birth and hypertension resolves by 12 weeks postpartum. This is a retrospective diagnosis.

What is preeclampsia?
A pregnancy-specific syndrome that usually occurs after 20 weeks gestation and is determined by gestational HTN plus proteinuria. There is also decreased placental perfusion and in severe cases, premature placental aging. There is the presence pathologic edema.

What eclampsia?
The occurrence of seizures in a woman with preeclampsia that cannot be attributed to other causes.

What is chronic hypertension?
HTN that is present and observable before pregnancy or that is diagnosed before week 20 of gestation.

What is preeclampsia superimposed on chronic hypertension?
Chronic HTN with new proteinuria or an exacerbation of HTN (previously well controlled) or proteinuria, thrombocytopenia, or increases in hepatocellular enzymes.

What are the characteristics of gestational or chronic HTN?
- B/P greater than 140/90
- mean arterial pressure (MAP) greater than 105 mm Hg
- diagnoses of onset during pregnancy based on 2 measurements that meet criteria for gestational BP elevation

Important labs for HTN
- CBC including platelet count
- Clotting studies (PT, PTT< fibrinogen)
- Liver enzymes (AST, ALT)
- Chemistry panel (BUN, creatinine, uric acid)
- Blood type and screen, possible crossmatch

What are the risk factors for preeclampsia?
- chronic renal disease
- chronic HTN
- family hx
- multifetal pregnancy
- primigravidity
- maternal age less than 19 greater than 40
- diabetes
- obesity

What is the physiological action in the body when preeclampsia occurs?
- vasospasms result in increased sensitivity to circulating pressors leading to and increase in BP
- increase in BP leads to decreased placental perfusion
- increased capillary permeability leading to edema
- to stop the syndrome the underlying cause needs to be removed

How is preeclampsia categorized?
As mild or severe.

When does preeclampsia occur?
Develops after 20 weeks of getstation in previously normotensive women.

Urine protein values
0 - negative
Trace - Trace
+1 - 30mg/dl
+2 - 100mg/dl
+3 - 300mg/dl
+4 - >1000mg/dl

What is important for a physical assessment of someone with HTN during pregnancy?
- **Blood Pressure** every hour
- Respirations, listen for crackles
- assess reflexes
- draw labs
- Level consciousness, headache
- urine output/dip
- edema
- epigastric pain

What needs to be watched with proteinuria?
the liver and kidneys

Platelet Count
In an adult, a normal count is about 150,000 to 450,000 platelets per microliter (x 10–6/Liter) of blood.

If platelet levels fall below 20,000 per microliter, spontaneous bleeding may occur and is considered a life-threatening risk.

Up to 5% of pregnant women may experience thrombocytopenia at term.

HELLP Syndrome
a rare but serious illness in pregnancy. This illness can start quickly, most often in the last 3 months of pregnancy (the third trimester). It can also start soon after you have your baby. HELLP stands for Hemolysis, Elevated Liver enzyme levels and a Low Platelet count. These are problems that can occur in women with this syndrome.

Women with HELLP syndrome may have bleeding problems, liver problems and blood pressure problems that can hurt both the mother and the baby.

the breaking open of red blood cells and the release of hemoglobin into the surrounding fluid

What are some complications of HELLP?
DIC, abruptio placentae, renal failure, pulmonary edema, ruptured liver hematoma

What condition can occur after severe preeclampsia?
eclampsia or HELLP

Nursing care for mild preeclampsia
- bed rest
- BP monitoring from home
- daily wt measurement & urine dipsticks
- fetal movement counts
- NST 1-2x/week

Biophysical profile (BPP)
A biophysical profile (BPP) test measures the health of your baby (fetus) during pregnancy. A BPP test may include a nonstress test with electronic fetal heart monitoring and a fetal ultrasound. The BPP measures your baby's heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid around your baby.

A BPP is commonly done in the last trimester of pregnancy. If you have a high-risk pregnancy, a BPP may be done by 32 to 34 weeks or earlier. Some women with high-risk pregnancies may have a BPP test every week or twice a week in the third trimester.

What is the drug of choice for the prevention of seizures caused by preeclampsia and eclampsia?
Magnesium Sulfate

How is Magnesium Sulfate administered?
Initial IV bolus given, then maintenance dose (piggyback).

Only given on a pump.

What is the therapeutic serum level for magnesium sulfate?

What is the antidote for magnesium sulfate overdose?
calcium gluconate

How long after birth do you infuse magnesium sulfate?
12-24 hrs

Signs and symptoms of magnesium sulfate toxicity
- resp <12/min
- hyporeflexia, lack of reflexes
- urine output <30 ml/hr
- toxic serum levels >9.6 mg/dl

What is hyperemesis gravidarum?
unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids." It is considered a rare complication of pregnancy.

What does hyperemesis gravidarum lead to?
dehydration, weight loss, electrolyte imbalance, ketosis, acetonuria

Spontaneous abortion
the loss of a fetus during pregnancy due to natural causes.

The spontaneous termination of a pregnancy before fetal development has reached 20 weeks. 12-25% of all pregnancies. 80-90% happen before 12th week and are a result of chromosome abnormality.

What does AMA mean?
advanced maternal age

What are pregnancy losses after the 20th week categorized as?
preterm deliveries

threatened abortion
the development of symptoms (bleeding with or without cramps or low back pain) that often suggest impending miscarriage. With such a presentation of bleeding, 50% proceed to miscarriage of the pregnancy.

Inevitable abortion
The miscarriage of a pregnancy is inevitable when any of the following symptoms are present:

- There is an obvious rupture of membranes
- An open cervix
- There is tissue in the cervix
- There is an absence of fetal heart at a βHCG level consistent with fetal heart activity

When any of these symptoms are detected, management involves conservative observation, monitoring for heavy bleeding and sepsis, and a dilatation and curettage (D&C).

Incomplete abortion
An incomplete abortion is the miscarriage of a fetus in a pregnancy when tissue has been passed, but some remains in utero. It can result in severe bleeding, infection or intrauterine scarring. Management consists of a dilation and curettage (D&C).

Missed abortion
A missed abortion is the miscarriage of a fetus in a pregnancy when the fetus has died, but remains in the uterus. The condition is also referred to as "delayed miscarriage". Many cases of missed abortion will lead to a spontaneous abortion within two weeks. Occasionally, a dilatation and currettage is necessary to remove the pregnancy tissue, done in reponse to the risk of maternal coagulation abnormality if the tissue remains in the uterus for several weeks.

What is an ectopic pregnancy? How are they classified?
Fertilized ovum implants outside of the uterus. They are classified by location.

What are the s/s of ectopic pregnancy?
Unilateral pain, vaginal spotting or bleeding (red or brown) and + pregnancy test.

What is the treatment for ectopic pregnancy?
Methotrexate (3.5cm or smaller) or surgery.

What is Gestational trophoblastic disease (GTD)?
It is actually a group of several diseases -- all involve abnormal growth of cells inside a woman's uterus. But unlike cervical cancer or endometrial (uterine lining) cancer, GTD does not develop from cells of the uterus. These rare, once fatal, but now highly curable tumors start in the tissue that begins to develop immediately after conception, when sperm from the father fertilizes an egg from the mother.

What are the two types of hydatidiform moles?
complete hydatidiform moles and partial hydatidiform moles

complete hydatidiform mole
develops mainly because a sperm has fertilized an “empty” egg (contains no nucleus or DNA). All the genetic material comes from the father’s sperm. Therefore, there is no fetal tissue. Up to 20% of patients with complete moles will need additional surgery or chemotherapy after their initial surgery. A small percentage of complete moles may develop into choriocarcinoma, a malignant form of GTD.

partial hydatidiform mole
develops when two sperm fertilize a normal egg. These contain some fetal tissue. But this tissue is often mixed in with the trophoblastic tissue. It is important to know that no viable (able to live) fetus is being formed. Only a small percentage of patients with partial moles need further treatment after initial surgery. Partial moles rarely develop into malignant GTD.

What's the treatment for molar pregnancies?
- most pass spontaneously
- suction curettage is safe, rapid, and effective if necessary
- induction of labor with oxytocin or prostaglandins not recommended

What can late pregnancy bleeding indicate?
- placenta previa
- abruptio placentae

Placenta previa
a condition that may occur during pregnancy when the placenta implants in the lower part of the uterus and is close to or covering the cervical opening to the vagina (birth canal).

How is placenta previa classified?
Based on the degree internal cervical os is covered by plancenta: complete or partial.

How is placenta previa diagnosed?
by transabdominal ultrasound examination, accurate 97% of the time.

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