Chapter 29: Promoting Premenstrual Health PDF

Ch. 29 Promoting Premenstrual, Perimenopausal and Menopausal Health Premenstrual Syndrome (PMS) - Affects many women during the reproductive years - Presence of behavioral, emotional and physical symptoms - Occurs during the luteal phase of the menstrual cycle - Stops within a few days...

Ch. 29 Promoting Premenstrual, Perimenopausal and Menopausal Health Premenstrual Syndrome (PMS) - Affects many women during the reproductive years - Presence of behavioral, emotional and physical symptoms - Occurs during the luteal phase of the menstrual cycle - Stops within a few days after the onset of menses - Phases: - Follicular/proliferative: from the end of menses through ovulation - Luteal: begins at ovulation and ends with the onset of menses - Menstrual: degeneration of the endometrium and onset of menses - Symptoms: More than 100 symptoms reported - Occur in a cyclical pattern - Occurs 5 days prior to menstruation - Ends within 4 days after the start of menstruation - Are not caused by any underlying physical or mental conditions - Keeps the individual from enjoying or doing normal activities -Symptoms must be relieved within 4 days of the onset of menses -No recurrence until at least day 13 of the cycle -Must be present in the absence of any pharmacologic therapy, hormone ingestion or drug or alcohol use -Identifiable dysfunction in social, academic or work performance - Management: physical activity, non-pharmacological treatment, NSAIDs, oral contraceptives or antidepressants Premenstrual Dysphoric Disorder (PMDD) - Most severe form of PMS, **[Mood Disorder.]** - Severe and disabling emotional symptoms - Symptoms: - Abdominal bloating - Anxiety - Tension - Breast tenderness - Crying episodes - Depression - Fatigue - Lack of energy - Irritability - Difficulty concentrating - Appetite changes - Thirst - Swelling of the extremities - Nursing intervention: take suicidal thoughts seriously, refer to a mental health professional, rule out illness that may be the source of symptoms and pay careful attention to the cyclical timing of the symptoms - Treatment:  Menopause - Phases: - Premenopause: from the beginning of perimenopause to the last menstrual period - Perimenopause: the time before menopause - Menopause: last menstrual period for at least one whole year without menstruation - Postmenopause - Physical changes: - Uterine lining thins and uterine muscle layer atrophies - Fallopian tubes/ovaries atrophy - Vaginal mucosa is no longer elastic - Decreased cervical gland function=dryness - pH in the vagina is elevated= atrophic vaginitis - Pubic hair thins and grays/labia shrinks - Loss of pelvic tone=incontinence - Breast loses density and is replaced by fat= more pendulous and less firm - Hot flashes (vasomotor symptoms) - Symptoms: - Hormonal changes - Menstrual cycle changes - Hot flushes/flashes, night sweats and sleep disturbances - Vaginal changes - Genitourinary tract changes - Skin and hair changes - Breast changes - Cognitive function changes (emotional instability, decrease in memory) - Long term effects: - Cardiovascular: increased BP, lipid changes, atherosclerosis - Muskuloskeletal: rapid bone loss, osteoporosis - Medications - Birth control pills - Progestin: release progesterone to reduce heavy, irregular menses - Low dose vaginal estrogen: reduces dryness and tissue damage in the vagina - Hormone therapy: for menopause symptoms - Bioidentical hormones - Estrogen therapy: prevents weakening bones and severe symptoms of early menopause - Testosterone: for menopause symptoms. Isn't FDA approved - Non-hormone medicines - Antidepressants: for hot flashes and irritability - Clonidine: high blood pressure for hot flashes - Gabapentin: antiseizure for hot flashes - Ospemifene: for vaginal changes that cause painful sex - Education: exercise (30 minutes 5 times a week), no smoking, maintain a normal BP, maintain a normal weight, eat a healthy diet, remain mentally active, prevent diabetes, deal with depression, hormone therapy until the natural age of menopause is reached - Diet: include salmon, moderate intake of alcohol - Estrogen: only if the patient has a hysterectomy or has an intact uterus Male Menopause (andropause) - A decrease in the production of male testosterone - Common in ages 40-60 - Causes: aging, stress, alcohol, medications, obesity, infections, elevation of SHBG (sex hormone binding globulin) - Risks: skeletal or cardiac system problems  Ch. 30 Promoting Breast Health Anatomy of the Breast - Breast tissue: glandular tissue, 15-24 lobes, each lobe contains several lobules, composed of numerous alveoli clusters around tiny ducts, fibrous and adipose tissue - Nipples, areolae and montgomery tubercles Benign Breast Masses - Risk factors: women between ages 30-5- - Breast cysts: can be either fluid filled or solid - Fibrocystic changes: tender and fluctuate in size with the menstrual cycle - Fibroadenomas: solid cysts composed of connective and glandular tissue - Lipoma: mobile, nontender fat tumors that are soft with discrete borders - Prevention: breast exams, breast self awareness and lifestyle choices (moderate alcohol consumption, weight maintenance and avoid smoking) - Screening: - USPSTF: biennial screening mammography for women ages 50-74 years - ACS: - annual mammograms and clinical breast exams for women ages 40-54 and then biennially starting at age 55 - Clinical breast exam about every 3 years for women 20-30 and every year for women older than 40 - An option for women starting in their 20's - ACOG: - Annual or biennially mammography for women ages 40-75 - Annual CBES for women ages 40 and older and every 1-3 years for women ages 20-39 - Encourage breast self-awareness for women ages 20 and older - Diagnostics: mammography, fine needle aspiration, core needle biopsy, surgical or open biopsy - Symptoms: - New lump in the breast or underarm - Thickening or swelling of part of the breast - Irritation or dimpling of breast skin - Redness or flaky skin in the nipple area or the breast - Pulling in of the nipple or pain in the nipple area - Nipple discharge other than breast milk - Any changes in the size of the shape of the breast - Breast pain (mastalgia) Breast Cancer - Risk factors: demographics, personal health history, lifestyle choices, defects in certain genes, 70-80% of women who develop breast cancer have none of the known risk factors - Demographics: advancing age, white women (black women have a higher mortality rate), previous diagnosis with cancer in one breast - Lifestyle factors: women who had no children or who had their first child after the age of 30, slightly greater risk in women who have used oral contraceptives, increased risk with postmenopausal combined hormone therapy, increased risk with being overweight or obese, vitamin D deficiency - Gene defects: - BRCA1 - BRCA2 - Related to 10% of ovarian and 3% of breast cancer cases - Those who are BRCA-positive also have a 50% chance of passing the mutation on to their offspring - Refer for clinical genetic testing for gene mutations - Treatment: surgery (lumpectomy, simple/radical mastectomy), radiation, chemotherapy, hormone therapy Tamoxifen - Effective against breast tumor cells that require estrogen for their growth - Blocks estrogen receptors on breast cancer cells - Activates estrogen receptors in other parts of the body, resulting in typical estrogen-like effects such as reduced LDL levels and increased mineral density of bone - Give with food or fluids, don't crush or chew, avoid antacids for 1-2 hours, pregnancy category D - Adverse effects: N/V, hot flashes, fluid retention, vaginal discharge, initial "tumor flare"- this is an expected therapeutic event, HTN and edema occur in about 10% of patients - Black box: increased risk of uterine cancer, slightly increased risk of thromboembolic disease (DVT, PE, stroke) - Contraindications: anticoagulant therapy, pre-existing endometrial hyperplasia, history of thromboembolic disease, pregnancy, lactation - Drug interactions: anticoagulants, cytotoxic drugs Breast Cancer in Men - Risk: men aged 72 years old - Symptoms: a lump is the most common symptom, redness, discharge Ch. 31 Promoting Reproductive Health: Various Gynecological Disorders Amenorrhea - Lack of menstruation - Primary: menstruation never takes place - Manage: correction of any underlying disorders and estrogen replacement - Secondary: - Menstruation starts and then stops - Absence of menses for at least 3 months in a woman with previously regular menses - Absence of menses for 6-12 months in a woman with previously irregular menses - Manage: cyclic progesterone, OCS, treatment of hyperprolactinemia, eating disorder, obesity, hypothalamic failure, hypothyroidism - Causes: pregnancy, breastfeeding, pituitary/ovarian/adrenal tumors, depression, chronic prolonged stress, hyper/hypothyroid conditions, rapid weight gain or loss, malnutrition, vigorous exercise, kidney failure, colitis, chemo/radiation, antidepressants, early menopause - Nursing interventions: tanner stages of development, lab testing, address diverse causes, psychosocial concerns, education Dysmenorrhea - Painful menstruation - One of the most common gynecological conditions - Pain develops during or shortly after the onset of menses - Can cause significant disruption with daily activities - Primary: intrinsic and early onset - Secondary: results from other physical causes Bacterial Vaginosis - Most common vaginal infection in women - Not considered to be an STD - r/t lack of hydrogen peroxide producing lactobacilli - Dramatic overgrowth of the vaginal resident bacterium - Signs and symptoms: - May be asymptomatic - Thin white or gray adherent discharge with a fishy odor, usually is worse after intercourse following menses - Pain, burning, itching and burning with urination - Risk factors: - Having a new sex partner or multiple sex partners - Having sex with someone with BV - Using vaginal products such as douching - Using feminine products such as washes and gels - Using products not designed for the vagina - Using an IUD - Diagnostic tools: vaginal wet mount, whiff test. - **[Treatment: Metronidazole (Flagyl) ]** Candidiasis - Yeast infection - Generally caused by candida albicans - Signs and symptoms: - May be asymptomatic - Intense vulvar itching - Thic, white, cottage cheese like discharge with a sour odor - Labial folds are red and edematous - Dysuria - Recognizing factors associated with vulvovaginal candidiasis - **[Treatment: Fluconazol]** Toxic Shock Syndrome - Rare, sometimes fatal - Believed to be associated with tampon use during menses, **[but not always caused by a tampon]** - Can also occur in children, pregnant women and non menstruating women - Signs and symptoms: - Fever of sudden onset greater than 102.2 - Flat erythematous rash - Vomiting, diarrhea, malaise, muscle aches - Disorientation - Low platelets - Hypotension - Strategies to reduce risk: use pads or choose a tampon with the minimum absorbency, wash hands before using a tampon and change tampons frequently (at least every 6 hours) - Diagnosis: CBC - Treatment: immediate hospitalization with fluid replacement and aggressive antibiotic therapy Urinary Tract Infections - Significant bacteria in the presence of symptoms - Causative organisms - Risk factors: women, extremes of age, altered immunity, anatomical anomalies, diabetes, urinary tract obstructions, pregnancy, sexual activity and diaphragm use - Signs and symptoms: - Dysuria - Urinary frequency - Urgency - A sensation of bladder fullness - Suprapubic tenderness - Cloudy, foul-smelling urine - Lower back pain (if infection ascended to the kidneys) - Diagnosis: based on symptoms, urinalysis, urine culture - Treatment: antibiotics - UTI risk among pregnant women - Patient education: recognize symptoms, void frequently, empty the bladder before and after intercourse, remain hydrated, drink fruit juice, take showers instead of baths Endometriosis - Growth, adhesion and progression of endometrial glands and tissue outside the uterine cavity - Etiology: not known, possibly retrograde menstruation - Pathogenesis: - Risk factors: early age at menarche, short cycles, low birth weight, nulliparity and heavy prolonged menstrual periods - Signs and Symptoms: - Pelvic pain 1 or 2 days before menses that is constant and debilitating - Diarrhea, pain with defecation, constipation and rectal bleeding - Dyspareunia, dysuria, various GI symptoms - Infertility - Menstrual dysfunction - Diagnosis: laparoscopy, vaginal ultrasound - Treatment: - Implications for nurses: Abnormal Uterine Bleeding - Painless endometrial bleeding that is prolonged, excessive and irregular and not attributed to any underlying structural or systemic disease - May be associated with major disruptions in daily functioning - Causes: - Palm: structural causes (polyps, adenomyosis, malignancy) - Coein: nonstructural causes (coagulopathy, ovulatory dysfunction, endometrial, not yet classified) - Therapeutic management: goal is to normalize the bleeding, correct the anemia, prevent or diagnose early cancer and restore quality of life - Pharmacotherapy or insertion of a hormone-secreting intrauterine system - Surgical intervention: dilation and curettage (D&C), endometrial ablation, uterine artery embolization or hysterectomy - Nursing interventions: history, symptoms, physical assessment Hysterectomy - Surgery to remove the uterus - Abdominal hysterectomy, Vaginal hysterectomy, Laparoscopic hysterectomy, Laparoscopically assisted vaginal hysterectomy, Robotic surgery Polycystic Ovary Syndrome - When endocrine imbalance results in: - Elevated levels of estrogen, testosterone and luteinizing hormone - Decreased secretion of follicle-stimulating hormone - Signs and symptoms: - Menstrual irregularity - Obesity - Hirsutism - Acne - infertility - Risks: insulin resistance may develop type 2 diabetes if they have PCOS, also risk for CAD, HTN and cancer - First line interventions: diet, exercise and weight loss - Medications: Myo-inositol Ch. 33 Reproductive Cancers Cervical Cancer - Malignant neoplasm that forms in the tissues of the cervix - Second most common type of cancer in women - Originates in the cells on the surface of the cervix - 80-90% are squamous cell carcinomas and most of the remaining are adenocarcinomas - Risk factors: HPV infection, cigarette smoking, immunosuppression, STD's, diet, early onset of sexual activity, inadequate cervical screening, male sexual partner who has had other partners, multiple sex partners, etc. - Symptoms: - Early cervical cancer usually produces no symptoms - May not experience problems until it is advanced and has spread - Screening and early detection: - Emphasize the importance of routine screening - Teach women about symptoms - Pap test techniques and follow up for abnormal results - Screening should begin at age 21 - The bethesda system: standardized the terminology used to describe the category of the epithelial cell abnormalities - Colposcopy: magnified view of the cervix - Endocervical sampling HPV - Double stranded DNA tumor virus - Most common STD in the U.S - More than 40 HPV types can affect cutaneous and mucosal surfaces, including the anogenital epithelium and the mouth and throat - Papillomas are not cancers and are more commonly called warts - Transmitted from one individual to another during skin to skin contact - Testing: a pap smear - Risk factors: a sexual partner more than 2 years older, more than 3 lifetime sex partners, a new sex partner in the past 12 months, engaging in drunk intercourse, never having been married or having a male partner who is not circumcised - Signs and symptoms: - Only 1% of people infected develop external genital warts - 10% develop cervical lesions - If lesions occur, most are the posterior part of the vaginal introitus - Vaccines: - Gardasil: for HPV 6, 11, 16 and 18 and the first HPV vaccine in the U.S - Gardasil9: for HPV 31, 33, 45, 52 and 58 - Cervarix: for HPV 16 and 18 - Education: should target both genders, listen attentively, use terms the adolescent understands, remain focused and avoid lectures and writing during the conversation Ovarian Cancer - Leading cause of gynecological deaths, **[can't screen for it!]** - 5th most common cause of cancer in women - Cause is unknown - Risk factors: increasing age, nulliparity, pregnancy later in life, obesity, history of breast cancer - Signs and symptoms: - "Whispering disease" because symptoms are vague until late in development - Any woman over 40 who has vague abdominal or pelvic discomfort, pain or enlargement, back pain, indigestion, urinary incontinence or sudden weight loss - Most common sign is is ascites  Endometrial Cancer - Most common gynecological malignancy - Most arise within the inner lining of the uterus - Adenocarcinomas - Risk factors: women ages 50-69, diabetes, obesity and any other condition causing premenopausal women to excessive levels of circulating estrogen, nulliparity and low parity, early menarche, late menopause, infertility - Cause is unknown - Diagnosis: pelvic exam, endometrial biopsy, fractional curettage, hysteroscopy and a transvaginal ultrasound - Treatment: total abdominal hysterectomy along with removal of the ovaries, fallopian tubes and local lymph nodes. Following surgery, RT, chemo or hormone therapy Ch. 32 STI's - Sexually transmitted infection (STI): the beginning phase, may not cause symptoms. - Sexually transmitted disease (STD): the result of an STI and describes the symptoms and the changes to the body as a result. - Sexual contact is the most common route of transmission but can be transferred through non-penetrating intimate exposure. - Complications: fallopian tube blockage which can cause infertility, increase risk of ectopic pregnancy, chronic pelvic pain, increased risk of liver cancer and death. - For treatment to be effective, sexual partners of infected individuals must be treated. - Two or more STI's frequently coexist. - Higher risk of contracting and transmitting HIV. - Nurses have a responsibility to teach sexually active clients how to prevent STI's. 5 P's to get an accurate sexual history: - Partners - Prevention of pregnancy - Protection from STI's - Practice - Past history of STI's Exposure to infants - Maternal infant transmission (transplacental, intrapartum and postpartum) Exposure to children - Screen for sexual abuse especially when anorectal symptoms/ disease/ trauma are found Exposure to teens - Females anatomy (sensitive columnar epithelia cells to invasion) - Feelings of invincibility - Unprotected intercourse - Partnerships of limited duration - Obstacles to using the healthcare system Exposure to older adults - Living longer, healthier and engaging in sex more - Increased utilization of meds to treat erectile dysfunction - Healthcare providers don't view them as sexually active Chlamydia Trachomatis - Most common STD in the US - Leading cause of preventable infertility and ectopic pregnancy - Transmission: through unprotected vaginal, anal or oral contact. - Risk factors: females, ages 15-24, more than one sexual partner, oral contraceptives, previous STI, unprotected sex. Signs and symptoms: - Depend on the area infected - Many people will be asymptomatic - Abnormal vaginal bleeding - Frequent urination - Dysuria - Pain during intercourse - Postcoital bleeding: spotting after intercourse - Cervicitis (infection of cervix) with mucopurulent (mucous and pus) endocervical discharge and friability (break easily). ex/ bleeding/mucous after swabbing cervix Diagnosis - Culture, direct immunofluorescence, nucleic acid hybridization and enzyme immunoassay (EIA). - Most specific: nucleic acid amplification test (NAAT) ( all of which require a pelvic exam to collect cervical epithelia cells), urine sample (clean catch) Treatment - Antibiotics (azithromycin (one time dose), doxycycline,erythromycin, levofloxacin Neisseria Gonorrhoeae - Gram-negative intracellular diplococcal bacterium - Second most commonly reported bacterial STI in the US - Transmission: sexual contact with penis, vagina, mouth or anus - Risk factors: women, ages 25 or younger, increased risk of infection (previous STI's) - Complication: pelvic inflammatory disease (PID) Signs and Symptoms - Majority of females are asymptomatic but are mild if present - Dysuria - Vaginal discharge - Vaginal bleeding - Irregular menses - Postcoital bleeding - Low backache - Urinary frequency Diagnosis - Gonorrhea and chlamydia testing are often performed together - Culture, nucleic acid hybridization and NAAT Treatment - Antibiotics (ceftriaxone and azithromycin) - Recommended CDC treatment - Abstain from intercourse for 7 days  Pelvic Inflammatory Disease (PID) - Acute infection of the uterus and fallopian tube - Develops in up to 40% of untreated women with cervical gonorrhea or chlamydia - Complications: infertility and tubal pregnancy from scarring of the fallopian tubes - Risk Factors: adolescents- 25 year olds, lower age of first intercourse, vaginal douching (flushing of vagina), cigarette smoking Signs and Symptoms: - lower abdominal tenderness - adnexal tenderness (mass near the uterus) - cervical motion tenderness (severe pain when the cervix is moved on exam) - Fever - Dysmenorrhea - Dysuria - dyspareunia (painful intercourse) - Peritoneal signs (shuffling gait) Diagnosis: - Endometrial biopsy, transvaginal ultrasound, laparoscopic exam Treatment: - Antibiotics, although they don't reverse scarring - Seek treatment immediately, could cause patient to become infertile - Oral fluids - Bed rest - Pain management Syphilis - Caused by a bacteria - A significant public health concern for pregnant women- can cause fetal anomalies - Transmitted: microscopic abrasions during unprotected sex (vaginal and anal) along with kissing, biting and oral. Spreads through blood and the lymph system or to the fetus through the placenta (congenital syphilis). - Can infect any body tissue or organ - Complications: severe systemic disease and death - Risk factors: unsafe sex, history of STD's, sexual partner who tested positive for syphilis, incarceration, working in sex trades and having sex with sex workers. - Stages: - Primary: painless ulcer (chancre) appears 10-90 days after exposure which lasts 4-6 weeks - Secondary: fever, sore throat, weight loss, skin rash, headache, malaise, mucous patches on genitalia or mouth, lymphadenopathy, hair loss, warts may appear after 6 weeks to 6 months which last 2-10 weeks if left untreated. - Latent: serological (antibodies) proof of infection without signs or symptoms. Early or late. - Tertiary: occurs 10 years after the initial infection, sometimes 30-5- years later. Gummas appear (soft, tumor-like balls of inflammation), neuropathic joint disease, neurosyphilis and cardiovascular syphilis. Trichomoniasis - Most common curable STD in the US - Caused by a parasite - Transmission: - Risk factors: unsafe multiple sex partners, previous hx of STDs, hx of working in the sex trade or having sex with them, recent incarceration, poor hygiene and substance abuse. Signs and Symptoms: - Profuse frothy gray or yellow-green vaginal discharge with a foul odor - Erythema - Edema - Pruritis of the external genitalia may be present - May have dysuria and dyspareunia Diagnosis: - A wet mount (wet smear) Treatment: - Metronidazole (95% cures it) Pediculosis Pubis (crabs) - Pubic lice, found on pubic hair, armpits, eyebrows, eyelashes, or beards. - Blood sucking parasitic insect. - Transmission: close person to person contact. Moves by crawling, unable to hop or fly. - Signs and symptoms: small flat blue-gray marks that look like small bruises and can last for several months, bloodstained underwear. - Diagnosis: based on hx, risk factors and symptoms - Treatment: Permethrin 1% cream rinse. Will not go away without treatment Scabies - Caused by an itch mite which burrows itself under the skin leaving eggs - Transmission: person to person through close contact or through bedding or clothing. - Signs and symptoms: intense itching (especially at night), pimplelike skin rash that may be on the hand, wrist, waist, feet, ankles, genitals and buttocks (warm areas) - Diagnosis: seeing the mite or eggs with the characteristics of the rash, examining mite under a microscope - Treatment: permethrin cream 5% followed by Crotamition lotion 10% Human Papillomavirus HPV - One of the most common viral STD's - Over 200 different types - Low risk: may cause benign genital warts - High risk: can change normal cells into **[cancerous]** cells - Transmission: skin to skin contact through sex but does not require penetration to be transferred. Signs and Symptoms: - Majority are asymptomatic and unrecognized - Warty growths in the vagina, vulva, perineum, inner thighs or anal area. - Warts can grow on the mouth, tongue, throat and lips - Warts are soft, fleshy, painless, and sometimes cauliflower shaped - Warts can take weeks to months to develop Diagnosis: - Visual confirmation, biopsy. Treatment: - May not be necessary because the warts can come back spontaneously. - Medicated ointment, cryotherapy, electrodesiccation or laser surgery. Prevention and vaccination: - Regular screening, pap tests, identify the precancerous lesions - Vaccines: Gardasil, Cervarix Herpes Simplex Virus (HSV) 1 and 2 - HSV-1: usually transmitted during childhood via nonsexual contacts (cold sores) - HSV-2: primarily an STD associated with genital lesions - Transmission: sexually, horizontally during close contact with an infected person who is shedding virus from the skin (saliva, genital secretions) Signs and Symptoms (in order): - Flu-like symptoms (malaise, muscle aches) - Dysuria - Prodromal symptoms (skin sensitivity and nerve pain in the area the lesions will appear) - Reddening of the skin - Appearance of painful fluid filled blister like ulcers (persists 2-3 weeks) - Lesions form pustules and ulcers that dry up, crust over and heal without scarring - Reactivates due to stress, hormonal or immunological change. - Recurrent infections 4-5 days Diagnosis: - History, physical exam - HSV serological testing is preferred - Cell culture - NAAT Treatment: - No cure - Hasten healing and reduce symptoms - Antivirals: acyclovir, valacyclovir, famciclovir Counseling and education: - Nurses should offer information about the possibility of suppression therapy to prevent partner transmission along with etiology, signs and symptoms and nodes of transmission. Advise that transmission can take place during the prodromal phase when symptoms recur. Ways to reduce HSV discomfort and outbreaks: - Warm sitz bath with baking soda or oatmeal - Wearing cotton underwear - Using a hair dryer (cool setting) to enhance drying of lesions - Compresses of peppermint oil and clove to the lesions - A cool, wet black tea bag or tea tree oil to the lesions - Meds: aspirin, ibuprofen - Diet: vitamin C, B, zinc, calcium, kelp powder and sunflower seed oil HIV/AIDS - HIV enters through genital routes, infects macrophages and then spreads to the lymph nodes which then affects various body organs including the brain and spleen - HIV leads to a progressive disease that results in AIDS (CD4 \< 200) - Transmission: body fluids (blood, seminal, vaginal, mother-to-child. - Risk factors: hx of working in sex trade, engaging in sex under the influence of drugs, intercourse with men who have sex with men, receiving blood transfusion before 1985, LGBTQ (high risk) Stages: - Stage 1 (500 lymphocytes) - Primary/asymptomatic: acute infection described as the worst flu ever 204 weeks after exposure, can last 8 years or longer - Stage 2 (200-499 lymphocytes) - Symptomatic - Stage 3 (less than 200 lymphocytes) - AIDS: susceptible to infections as the level drops below 100 Signs and Symptoms: - Effects on cognition, motor function - Peripheral neuropathy - HIV encephalopathy - Herpes zostercanScreening and early detection: - Emphasize the importance of routine screening - Teach women about symptoms - Pap test techniques and follow up for abnormal results - Screening should begin at age 21 - Genital ulcers - PID - Menstrual abnormalities - Oral candidiasis - Diarrhea - Wasting syndrome - Respiratory: - Pneumocystic carinii pneumonia (PCP): nonproductive cough, fever, chills, dyspnea, chest pain and could cause respiratory failure. - Mycobacterium avium complex (MAC) - TB - Oncologic - Kaposi's sarcoma: lesions that cause discomfort, disfigurement, ulceration and potential for infection (kind of look like blood blisters) - B-cell lymphoma - Cervical cancer Signs and Symptoms pediatric: - HIV encephalopathy (may be first clinical presentation) - Failure to thrive - Recurrent bacterial infection - Chronic diarrhea - Fever - Developmental delay - Motor deficits Diagnosis: - Labs: EIA, CD4/CD8, viral load Treatment: - Monitoring CD4 count (\ - Males: - Leydig cells: LH stimulates these cells in the testicles to mature the testes and begin testosterone production. - Testicular enlargement: caused by testosterone secretion and is the first sign of puberty The Menstrual Cycle and Reproduction - Uterine Cycle Phases: - Menstrual: the time of vaginal bleeding - Proliferative: end of menses through ovulation - Secretory: ovulation to the period just before menses - Ischemic: end of the secretory phase to the onset of menstruation - Hypothalamic-Pituitary-Ovarian Cycle: hormones interact to influence the secretion of hormones from other sites (GnRH, LH, FSH, estrogen and progesterone) - Follicular Phase: day 1 of menses for about 14 days where there is a dominance in estrogen, FSH and LH. - Luteal Phase: ovulation to the onset of menses where if pregnancy is not achieved the corpus luteum dominates the second half of the menstrual cycle Natural Cessation of Menses - Climacteric: decline in ovarian function - Perimenopausal: time preceding menopause - Menopause: last menstrual period - Postmenopausal: time after permanent cessation of menses Menstrual Disorders - Amenorrhea: absence of menses - Dysmenorrhea: Painful uterine cramping - Premenstrual syndrome: range of symptoms associated with menstruation Contraception - Natural family planning (NFP): identifying the fertile time period and avoiding intercourse during that time. - Fertility awareness methods (FAMs): identifies the fertile time period during the cycle and uses abstinence or other contraceptive methods during fertile periods. Behavioral - Coitus interruptus: \"withdrawal method", pulling out. - Lactational amenorrhea method (LAM): breastfeeding as a use of contraception. - Abstinence: 100% effectiveness rate Barrier - Diaphragm: latex dome-shaped device with a spring rim - Cervical cap: silicone device that fits around the base of the cervix similar to the diaphragm but smaller - Condoms - Spermicides: chemical barriers that kill the sperm before they enter the cervix - Contraceptive sponge: spermicide that fits over the cervix - Oral contraceptives: 93% effective in preventing pregnancy - Low-dose progestin-only contraceptive pills: contain 0 estrogen. Ovulation may occur - Transdermal contraceptive patch:low levels of estrogen and progestin absorbed into the skin - Vaginal contraceptive ring: a ring inserted deep into the vagina by the 5th day of the menstrual cycle and left in for 3 weeks to allow withdrawal bleeding and a new ring is put in - Injectable hormonal contraceptive methods (Depo), emergency contraceptive pill (plan B), IUD, female/male sterilization. Infertility - Labs: STI, thyroid, GTT, FSH/LH, testosterone, etc. - Male evaluation: sperm number, size, shape and motility - Treatment: - Meds: Clomiphene citrate, - Surgery: ablation of endometrial implants for endometriosis, transcervical tuboplasty (correction of fallopian tube abnormalities). - Therapeutic insemination: placing semen at the cervical os or directly in the uterus. - Assisted reproductive technologies (ART): placing the ova and sperm together to promote fertilization. Includes gamete, intrafallopian, zygote, frozen embryo and IVF-embryo transfers. Assessment: - Males: semen analysis, sexual characteristics, external and internal reproductive organ exam, digital prostate exam. - Females: ovarian function, pelvic organs - Diagnostics: home ovulation predictor kits, hysterosalpingogram, laparoscopy. Nursing Interventions: - Respect for the couple - Education - Assistance in decision making - Assistance with financial strategies Ch. 3 Conception and development of the embryo and fetus Terms -Gregor Mendel is a scientist that proposed that the strength of some characteristics explains the variations in patterns of inheritance. Genetics: study of single genes and their effects Genomics: study of the functions and interactions of all genes Genome: a complete copy of genetic material in an organism Gamete: a mature germ cell DNA: genes that carry instructions Gentotype: genetic makeup. Complete set of genes present. Phenotype: Observable expression of the genotype (physical features/traits). Gene pairs: - Homozygous: if the gene pairs are identical - Heterozygous: if the gene pairs are different Chromosomes: threadlike packages of genes and other DNA - All normal somatic (body) cells contain 46 chromosomes arranged as 23 pairs of homologous (matched) chromosomes. - One chromosome of each pair is inherited from each parent - 22 of the pairs are autosomes (nonsex chromosomes that are common in both male and females) and there is one pair of sex chromosomes that determines gender. Disease Inheritance - Multifactorial inheritance: the cause of most congenital malformations. A combination of genetic and environmental factors. ex/ cleft lip - Unifactorial inheritance: a pattern of inheritance that results when a specific trait or disorder is controlled by a single gene - Autosomal dominant: either from a family of multiple generations that have the disorder or a mutation (first time in the family). Ex/ Huntington\'s disease, Marfan's syndrome. - Autosomal recessive: when both members of an autosomal gene pair are altered. When each parent carries the recessive altered gene and pass it to their offspring. - X-linked dominant: alteration in a gene located along the X chromosome (more common in females because they have XX chromosomes) Abnormalities in sex chromosomes - Turner syndrome: chromosomal deviation in females. All or part of one X chromosome is missing. (webbed neck, broad chest, heart murmur) - Klinefelter's syndrome: chromosomal deviation in males. Trisomy XXY. Extra X chromosome (gynecomastia, sterility) Cellular Division - Meiosis: occurs during gametogenesis. Daughter cells are exactly alike. Leads to the development of sperm and ova. - Mitosis: formation of 2 identical cells that are exactly the same as the original cell Fertilization 1. Meiotic division 2. Oocyte is expelled during ovulation 3. Oocyte travels to infundibulum in fallopian tube 4. 200-600 million sperm deposited around cervical os 5. Sperms undergo capacitation (changes sperm goes through to be able to fertilize the ovum) 6. Enzymes from the sperm's head are released The Placenta - Develops from the trophoblast cells - Essential for the transfer of nutrients and oxygen to the fetus and removes waste from the fetus  Development of the embryo and fetus - The yolk sac develops in the embryo's inner cell mass - Umbilical cord connects the embryo to the yolk sac - Wharton's jelly: connective tissue that surrounds the umbilical cord - Two arteries and one vein The fetal circulatory system - Ductus venosus: connects the umbilical vein to the inferior vena cava - Foramen ovale: an opening in the septum between the right and left atria - Ductus arteriosus: channel between the pulmonary artery and descending aorta - The placenta is the site of oxygenation and waste elimination Chorion: outer membrane of the amnion, embryo and yolk sac - Chorionic villi: fingerlike projections Amnion: inner membrane that contains amniotic fluid Fetal Period (weeks) - 9-12: face becomes recognizable, body growth increases, intestines leave the umbilical cord and enter the abdomen. By week 12 the genitalia are distinguishable. - 13-16: very rapid growth. Ossification of the skeleton, bones become clearly visible on ultrasound, ovaries are differentiated. - 17-20: growth slows, maternal awareness of fetal movements, skin is covered with a thick cheeselike material (vernix caseosa), hair grows on head and eyebrows, subcutaneous deposits of brown fat for heat, female uterus is formed. - 21-25: fetus gains significant weight, skin appears pink or red because blood flow is now visible, fingernails, lungs begin to secrete surfactant - 26-29: lungs can breathe air (fetus can survive if born) and the CNS can regulate body temperature and direct rhythmic breathing, eyelids open, toenails evident, subcutaneous fat under the skin. - 30-34: pupillary light reflex is present - 35-40: strong hand grasp reflex and orientation to light. Preventing neural tube defects NTD: - Defects in the skull and spinal column from a failure of the neural tube to close - Folic acid decreases the incidence of NTD. Women should consume 0.4-0.8 mg daily. Factors that can adversely affect embryonic and fetal development: - Chromosomes (genetic defects) - Teratogens (environmental hazards) - Fat-soluble vitamins: poor fetal growth, rickets, poor enamel - Alcohol: fetal alcohol spectrum disorder (FASD) - Tobacco: low birth weight and preterm labor (vasoconstriction) - Caffeine: more than 300mg daily can cause miscarriage - cocaine and crack: neurological and behavioral problems, stillbirth, fetal distress, strokes, seizures, congenital malformations - Opiates: prematurity, sudden infant death, impaired bonding - Sedatives: withdrawal syndrome, seizures and delayed lung maturity - Amphetamines: prematurity, placental abruption, cleft palate - Cannabis: preterm birth, placental abruption, stillbirth - Along with radiation, lead, pesticides and methylmercury. - TORCH infections - Toxoplasmosis: parasite. Flu-like symptoms and can damage eyes/brain. - Other transplacental infections: HIV, hep B - Rubella: respiratory droplets. Miscarriage, cataracts, death - Cytomegalovirus: respiratory droplets. Death, jaundice, cerebral palsy and deafness - Herpes simplex virus: miscarriage, preterm, seizures, coma Trisomy: when a fetus develops with 3 chromosomes instead of 2. - Trisomy 13: Patau syndrome. Rare. Poor prognosis. - Trisomy 18: Edwards syndrome. Rare. Poor prognosis - Trisomy 21/22: Down syndrome Twins: - Monozygotic: identical - Conjoined: embryonic disk does not divide completely or when the adjacent embryonic disk fuses - Dizygotic: fraternal Abbreviations: **G**ravida **T**erm **P**remature **A**bortion **L**iving G: number of pregnancy P "para": number of living "G 3 P 2" or "G3 P1011" = one living one miscarriage one living one living ON TEST LMP last menstrual period DUE DATES: all ways to say due date - EDC: estimated date of confinement - EDB: estimated date of birth - EDOD: estimated date of delivery Count weeks and days. Need to be exact. Need to know how far along the system development is. Antepartum patients: - Multiple births: high risk - Preterm labor - PIH pregnancy induced hypertension - Gestational diabetes - Placenta previa: placenta covers cervix - Placental abruption: placenta tears away from uterine wall - Fetal through issues: IUGR (intrauterine growth restriction) Dilation Effacement: how thick the cervix is Station: where the presenting part is in the pelvis Stages of Labor: - First stage: early, active, transition - Second stage: babies here! - Third stage: placenta - Fourth stage: recovery - Hemorrhage - Uterine atony - Laceration - Infections - Mastitis - Thrombophlebitis Ch. 4 Physiological and Psychosocial Changes During Pregnancy Changes to the Uterus - Increased blood flow - Myometrial and muscle fibers undergo hyperplasia and hypertrophy (processes that allow the uterus to enlarge and stretch as the fetus grows) due to progesterone - Changes in size, shape and position - Estrogen causes the uterine muscles to contract - Braxton-Hicks contractions - Irregular and painless - May begin as early as the 16th week Measuring Fundal Height - Measured in centimeters - Correlates with the gestational age of the fetus - Using a soft tape measure, measure from the top of the pubis bone to the top of the fundus - Should correlate with the week\'s gestation +/-2 weeks. If greater or less than 2 cm/week difference warrants further testing. Cervix - Chadwick's sign: one of the earliest signs of pregnancy, bluish-purple discoloration that appears on the cervix - Goddell's sign: estrogen and progesterone causes cervical softening Vagina and Vulva - Vaginal mucosa thickens and rugae (vaginal folds) is more prominent - Estrogen and progesterone cause the cervical glands to produce a lot of mucous - Operculum: mucus plug. Helps keep harmful agents out of the uterus Ovaries - Ovulation stops - hCG maintains the corpus luteum (which makes your uterus a healthy place for the fetus to grow) - Once the placenta has developed, it takes over progesterone production. Breasts - Breast enlargement, fullness, tingling and increased sensitivity - Prominent superficial veins - Montgomery tubercles (sebaceous glands) provide lubrication for nipple tissue - Striae gravidarum (stretch marks) may develop - Precolostrum (clear thin fluid) and colostrum (creamy whitish-yellow liquid) may develop in 16 weeks gestation. Cardiovascular - Heart shifts upward and to the left - Heart rate increases by 10-15 bpm - Cardiac output increases - Uterus exerts pressure on the diaphragm - Blood volume increases 40-50% - Decrease in systemic and pulmonary vascular resistance - BP decreases slightly Cardiovascular Issues - Physiologic anemia of pregnancy: due to increase in total plasma volume - Supine hypotension syndrome/ vena caval syndrome: faintness related to bradycardia if she lies on the back from the pressure of the uterus. - Lie on left side or semi-fowlers - Wedge under hip if supine is necessary Hematology - Increased maternal blood volume by 40-50% - Increased blood flow to the uterus - Lower HGB and HCT - Increased leukocytes - Decreased platelets and albumin - Fibrinogen volume may increase as much as 50% - Increased plasma proteins Respiratory: - Tidal volume increases - Increase O2 consumption by 15-20% - Increased vital capacity - Chest circumference increases by 2.4 inches - Loss of vertical diaphragm movement but increased lateral movement - Dyspnea - Vascular congestion of nasal mucosa Eyes and Nose - Blurred vision from corneal thickening - Changes regress by 6-8 weeks postpartum - Nasal stuffiness and congestion - Due to progesterone and estrogen - Edema of the nasal mucosa - Epistaxis may occur Oral - Gingivitis - Ptyalism gravidarum: excess saliva production - Hyperemesis gravidarum: excessive and persistent N/V - Pyrosis: heartburn Liver and Gallbladder - Stasis of bile (gallbladder relaxes) - Altered liver function due to additional workload - Increased risk for gallbladder inflammation or infection - Prolonged emptying time - Elevated cholesterol levels Hemorrhoids - Straining because food remains in the stomach longer and contents move more slowly through the small intestine and large intestine Urinary - Relaxation of urethra, sphincter and bladder - Reduced peristalsis - Elongation and dilation of the ureters - Enlarging uterus can obstruct urine flow - Increased risk for UTI's - Kidneys enlarge slightly Musculoskeletal - Abdominal wall weakens - Lumbar lordosis - Lower back pain - Lax (loose) sacroiliac joint (joint in pelvis and sacrum) - Widened symphysis pubis - Waddling gait - Center of gravity changes Integumentary - Linea nigra: dark line from umbilicus to mons pubis - Chloasma (melasma gravidarum): brownish pigmentation - Striae gravidarum: stretch marks - Palmar erythema: reddish-pink mottling of hands Signs of pregnancy - Presumptive: subjective signs (morning sickness, absence of menses) - Probable: objective signs (abdominal enlargement, positive pregnancy test) - Positive: presence of a fetus (fetal heartbeat, visualization on ultrasound) Establishing the EDB - Early term---births between 37 weeks 0 days and 38 weeks 6 days - Full term---births between 39 weeks 0 days and 40 weeks 6 days - Late term---births between 41 weeks and 0 days and 41 weeks 6 days - Postterm---births 42 weeks 0 days or after Naegles Rule - How we calculate EDB - Date of LMP + 7 days - 3 months ex/ LMP was June 8th, 2014 + 7 days= June 15, 2014 - 3 months= March 15, 2015 Common Discomforts During Pregnancy - N/V - Fatigue - Ptyalism (excessive spit) - Dyspepsia (indigestion) - Dental issues - Nasal congestion - Hyperventilation and SOB - Upper and lower backache - Leukorrhea. - Urinary frequency - Leg cramps - Dependent edema - Varicosities - Round ligament pain - Carpal tunnel syndrome Psychosocial Adaptations - **[AMBIVALENCE]** - The healthy mind - Readiness for motherhood - Body image changes - Anxiety - Developmental and family changes - Acceptance - Reordering relationships Nursing Assessment of psychosocial changes - Assess for intimate partner violence at every prenatal visit - Signs of IPV: missed appointments, frequent STI's, placental abruption Ch. 5 Promoting a Healthy Pregnancy Choosing a Pregnancy Care Provider - Obstetrician - Family practice physician - Certified nurse midwife - Prenatal care Preconception Care: period of time before pregnancy - Family planning - Building a foundation for a healthy pregnancy - Identify conditions that could adversely affect a future pregnancy - Reproductive life plan Prenatal Care: care during pregnancy - Fetal assessments - Screening and testing - Risk factor assessments - Education First Prenatal Visit - Extremely important and should take place as early in pregnancy as possible - Biographical data - Should be: - Every 4 weeks until 28-32 weeks of pregnancy - Every 2 weeks until 36 weeks of pregnancy - Then weekly until delivery - Information about current pregnancy - Medical history - Vaccination history - Obstetrical history - Pregnancy classification system (GTPAL) - Family history - Environmental health assessment - Social: tobacco, alcohol, cannabis, cocaine, STI's - Genetics: pregnancy associated plasma protein-A, free hCG, triple screen, quadruple screen, biochemical markers, early diagnosis of birth defects - Physical exam: general (height, weight, BMI), head, neck, lungs, skin, breast, abdomen (uterine size), fetal heart auscultation, vagina and pelvis Prenatal Labs  Diet of a pregnant mom - Protein - Water - Prenatal vitamins - Prevention of foodborne illness (salmonella and listeria) - Avoid mercury exposure, caffeine and artificial sweeteners, certain herbs - Calories - First trimester: no additional calories needed - Second/Third: 300 additional cal needed per day - Breastfeeding: 450-500 additional cal per day Planning daily food intake: - Variety of nutrient dense foods - Balanced daily eating pattern - Iron, vitamin C, folic acid - 8-12 oz of seafood per week (limit tuna, shark, swordfish and king mackerel) Weight gain during pregnancy due to - Increased blood volume - Enlargement of the placenta - Fetal body - Monitor weight gain closely during pregnancy - Low and high BMI during pregnancy associated with complications - Recommended weight gain should be individualized Eating disorders - PICA: consumption of nonnutritive substances (clay, dirt, cornstarch, ice) - Anorexia nervosa: excessive dieting or purging - Bulimia nervosa: binge eating, self induced vomiting and diarrhea. Vegetarian diets - Semivegetarian: fish, poultry and eggs - Ovolactovegetarian: consume plant and dairy products - Strict: only plant products. Deficient in B12. Should consume fortified foods. Oral Health - Periodontal disease - Acid may coat the teeth and wear down enamel - Gingivitis in second trimester - May require a dentist Exercise - Encouraged unless contraindicated - Regular, moderate intensity for 30 minutes or more a day - Muscle strengthening is beneficial - Monitor breathing during activity - No activities that can cause abdominal trauma - Adequate fluid intake Travel - Safe throughout most of pregnancy but could put you at risk for DVT if traveling long. Carry obstetrical medical record Work - Make a decision depending on if you should continue to work based off of environmental factors, heavy lifting or safety Rest - First trimester: progesterone increases feelings of fatigue - Second trimester: some experience increased energy some experience fatigue - Third: increased fatigue as the fetus grows and develops Danger signs: vaginal bleeding, sudden gush of fluid from vagina, severe headaches with blurred vision, severe abdominal pain, fever, difficulty breathing, feeling ill, decreased fetal movement Assessment of the Fetus During Labor and Birth. - Fetal position: by palpating the abdomen (leopold's maneuvers), locating the point of auscultation of the FHR, a vaginal exam and an ultrasound. - Assessment of the fetal heart rate: external fetal monitoring, auscultating fetal heart sounds and electronic fetal heart rate monitoring. Leopold's Maneuvers 1. Determine which fetal body part occupies the fundus by gently palpating the fundal region of the uterus. Breech feels soft, the head feels hard. 2. Determine the location of the fetal back by palpating the sides of the uterus by holding the left hand steady and palpating with the right to feel for a back or arms/legs and switch hands. 3. Confirming step one and feeling for engagement by gently grasping the lower portion of the maternal abdomen above the symphysis pubis and pressing the thumb and index finger together. If they can be pressed together, it is not engaged 4. Determine the fetal attitude by turning to face the patient\'s feet and using both hands to outline the fetal head with fingers pointed towards the pelvic inlet to determine whether the head is flexed or extended. Electronic Fetal Monitoring - Continuous tracing of fetal heart rate - Observation, evaluation - Ongoing monitoring and interpretation of data - Advanced assessment - Healthcare professional with education and skills - Three-tiered categorization of EFM patients  External Monitoring - Doppler ultrasound transducer that is applied to the maternal abdomen over the fetal back to monitor FHR and contractions. - Produces continuous graphic recording - Susceptible to interference from maternal and fetal movement Internal Monitoring - Fetal scalp electrode FSE - Cervix must be dilated at least 2 cm - Membranes must be ruptured - Electrode attached to presenting part - Risk of transmission of known maternal infections - Instantaneous continuous recording  External Internal Fetal Heart Rate Patterns - Continuously measured intervals between fetal heartbeats - Described by: - Mean FHR during a 10 minute period (rounded to 5 bpm with accelerations and decelerations excluded) - Must be observed for 2 minutes - 110-160 bpm - Tachycardia: over 160 bpm for over 10 minutes - Causes: - Nonreassuring with other FHR patterns - Late or severe variable decelerations - Decreased or absent variability - Bradycardia: under 110 for at least a 10 minute period - Causes: vagus nerve stimulation, drugs, maternal hypotension, fetal hypoxemia or dysrhythmia - Sinusoidal FHR pattern: smooth wavelike undulating sine pattern - Causes: fetal anemia, chronic fetal bleeding or fetal isoimmunization -Variability  -FHR changes - Accelerations and decelerations - Episodic changes not associated with uterine contractions - Periodic changes with 50% or more of UCs in 20 minute period categorized as recurrent - Accelerations (accels) - Visually apparent increase in FHR - Prolonged: 2 minutes but less than 10 minutes - Decelerations (decels) - Decrease in FHR - Episodic or periodic decelerations - Early: could be caused from fetal head compression - Usually symmetric, gradual decrease - Calculated from onset to nadir (lowest point of deceleration) - Nadir occurs at the same time as peak of contraction - Result of vagal nerve stimulation - Normally reassuring - Variable: could be caused from umbilical cord compression - Abrupt decrease in FHR - Usually only occurs when: less than 70 bpm, lasts more than 60 seconds and is slow to return to baseline - Late: could be caused from uteroplacental insufficiency - Usually symmetric, gradual decrease - Associated with uterine activity - Nadir occuring after peak of contraction - Required immediate interventions - Position changes - Increased IV fluids - Oxygen via face mask - Stop IV pitocin if infusing - Notify physician, certified nurse-midwife - Prolonged: decrease in FHR of 15 bpm or more below BL for more than 2 minutes, less than 10 - Tachysystole (hyperstimulation) - A single contraction lasting 2 minutes or more, or five or more contractions in a 10 minute period averaged over 30 Ch. 6 Caring for the Woman Experiencing Complications During Pregnancy Ectopic Pregnancy - When the fertilized egg implants outside of the uterus - Risk Factors: history of STI or PID, prior ectopic pregnancy, previous tubal, pelvic or abdominal surgery, endometriosis, IUD, in-vitro fertilization - Hallmark sign: unilateral stabbing pain in the lower quadrant - Ruptured: can lead to extreme blood loss, shock and death Labs: - Beta-hCG: low can be a sign - Blood type: in case of rupture, ectopic or surgery - Rh: Rhogam if she is Rh negative - CBC - WBC Diagnosis: - Transvaginal ultrosonography (to confirm if intrauterine or tubal) - If ultrasound is inconclusive, serial BhCG will be performed - Pelvic exam to confirm a mass Management: - Salpingectomy: removal of fallopian tube - Salpingostomy: incision into fallopian tube to remove the pregnancy - Methotrexate: chemo drug and folic acid inhibitor that stops all rapid cell production Gestational Trophoblastic Disease - Hydatidiform mole or molar pregnancy - Abnormal placental development that results in the production of fluid-filled grapelike clusters - Associated with a loss of pregnancy and rarely the development of cancer Signs and Symptoms - Absence of fetal heart sounds - Elevated serum hCG - Very low levels of maternal serum fetoprotein - Vaginal bleeding that may be scant or profuse - May pass part of the molar pregnancy - Discrepancy between uterine size and dates - N/V Management - Removal of uterine contents - Early stages: suction dilation and curettage - Some women may need a hysterectomy - Chemo if hCG rises - Surgery if chemo is not successful - Radiation for brain and liver metastases Spontaneous Abortions (SAB) - Complete abortion: complete expulsion of all POC (products of conception) before 20 weeks gestation. - Incomplete abortion: partial expulsion of some but not all POC before 20 weeks gestation. - Inevitable abortion: No expulsion of POC but bleeding and dilation of the cervix has occurred and expulsion of POC cannot be halted. - Threatened abortion: signs of SAB are present with intrauterine bleeding before 20 weeks, without dilation of the cervix; the fetus is still alive and attached to the uterus. - Missed abortion: death of the embryo or fetus before 20 weeks with complete retention of the POC; these often proceed to a complete abortion within 1-3 weeks but occasionally are retained up to 8. - Septic abortion: POC and/or uterus become infected during the abortion process. - Recurrent abortion: three or more pregnancies have ended in SAB, often due to genetic, chromosomal or anatomical irregularities. - Elective/therapeutic abortion: the POC are removed for medical reasons in which the fetus has a condition incompatible with life, when the woman\'s health is in danger or for personal reasons. Cervical Insufficiency - Formerly called cervical incompetence - A painless cervical dilation resulting in 2nd-trimester pregnancy loss - Diagnosis: transvaginal cervical ultrasonography during the 2nd trimester may be used to assess risk or monitor - Treatment: reinforcement of the cervix with suture material (cerciage) Hyperemesis Gravidarum - Extreme persistent, continuous N/V during pregnancy that, unlike morning sickness, can cause complications - Most common reason for hospitalizations during pregnancy - Complications: electrolyte imbalance, dehydration, alkalosis, ketonuria, discrete weight loss - Diagnosis: exclude other disorders that can cause vomiting based on the symptoms, determine severity by measuring electrolytes, ketones, BUN, creatinine and body weight - Treatment: suspend oral intake at first, give fluids and nutrients IV, restore oral intake gradually and give antiemetics as needed. Bleeding Disorders Later in Pregnancy - An obstetric emergency - Leading cause of maternal health in the US - Early identification of maternal hemorrhage: pt may be asymptomatic but the maternal pulse (tachycardia) and/or fetal heart rate (brady/tachycardia) may be the first indicators - Placental causes of vaginal bleeding Placenta Previa  Signs and Symptoms: Painless, bright red vaginal bleeding Key Points: - Typically manifests as painless vaginal bleeding after 20 weeks and placental abruption is usually associated with uterine pain and tenderness; however, clinical differentiation is often not possible. - Consider placenta previa in all women who have vaginal bleeding after 20 weeks - For most first bleeding episodes before 36 weeks, recommend hospitalization, modified activity and abstinence from sex - Consider corticosteroids to accelerate fetal lung maturity if delivery may be required before 36 weeks or if bleeding occurs between 34 and 36 weeks in patients who have not been given corticosteroids before 34 weeks - Cesarean delivery is indicated when the mother or fetus is unstable or if the mother and fetus are stable at 36 weeks/0 days- 37 weeks/6 days. Placental Abruption (Abruptio Placenta) - Premature separation of a normally implanted placenta - Risk factors: older maternal age, HTN, placental ischemia, intraamniotic infection, vasculitis, prior abruption, abdominal trauma, maternal thrombotic disorders, tobacco, cocaine, premature rupture of membranes. - Complications: maternal blood loss, fetal compromise  -slight vaginal bleeding -absent to moderate uterine -bleeding severe --some uterine irritability bleeding -uterus is painful -uterus is irritable/contractions -maternal hypotension \- maternal pulse is elevated -fetal death \- blood volume deficits -low fibrinogen \- fibrinogen level may low -coagulation problems -fetal HR may show problems Signs and Symptoms - Depends on the degree of separation and blood loss - Classic presenting sign is third trimester bleeding associated with severe abdominal pain Nursing interventions: - IV placement - Labs: CBC, coagulation studies, type and screen - RhoGAM - Cesarean delivery - Continuous fetal assessments Preterm Labor - Cervical changes and regular uterine contractions occurring between 20 and 37 weeks - Risk factors: abruption, cervical insufficiency, hormonal changes, STI's and bacterial infections Diagnosis - Fetal fibronectin testing - Assessment of cervical length and funneling Signs and Symptoms - Contractions that may be painful or painless - Lower back pain - GI upset, cramping or diarrhea - Pelvic pressure or fullness - Vaginal discharge/blood - Vaginal discomfort pressure Management - Antibiotics - Tocolytics - Corticosteroids - Bed rest and hydration Nursing interventions - Include the partner and educate - Positioning on side for better placental perfusion - Explain side effects - Assess vitals - Assess for pulmonary edema - Continuous fetal monitoring - Prevent by educating patients and family before it happens Premature Rupture of the Membranes (PROM) - Occurs before the 37th completed week of gestation - Absence of labor - Causes: most common is infection or bacteria in the genital tract - Patient reports a gush or leakage of fluid from the vagina - Any increased vaginal discharge should be evaluated Pre-eclampsia - Pregnancy specific systemic syndrome clinically defined as an increase in BP, occurring twice, 4 hours apart after 20 weeks gestation accompanied by proteinuria - Eclampsia: presence of new-onset grand mal seizures in women with pre-eclampsia who has no other cause for seizure - Risk factors: primigravida, ages \