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MODULE 4M: FEMALE REPRODUCTIVE SYSTEM The main external structures of the female reproductive system include: ○ Labia majora Reproduction is...

MODULE 4M: FEMALE REPRODUCTIVE SYSTEM The main external structures of the female reproductive system include: ○ Labia majora Reproduction is an essential part of the human life cycle for the continuity of the ○ Labia minora human race. The importance of early and continuous health supervision during ○ Bartholin’s gland pregnancy is paramount for the total well-being of the mother and her infant. Such ○ Clitoris care is necessary so that serious problems can be averted or controlled by prompt The internal reproductive organs in the treatment and care. Without these measures, the pregnant mother may face greater female include: risk of experiencing alterations in reproduction. ○ Vagina ○ Uterus/womb (has 3 parts) Sexuality is intrinsic to our being. A basic need and therefore cannot be separated Fundus from life events. It influences our thoughts, actions, and interactions and involves the Body aspects of physical and mental health. Cervix ○ Ovaries Review on the Anatomy and Physiology of the Female Reproductive System ○ Fallopian tubes Designed to carry out several functions Produces the female egg cells Menstrual Cycle necessary for reproduction called Begins with the menstrual phase the ova or the oocytes It is when the woman gets her period The system is designed to This phase starts when an egg from the transport the ova to the site of previous cycle is unfertilized fertilization which results to Because pregnancy has not taken place, conception levels of the hormones estrogen and ○ Conception is the progesterone drop fertilization of an egg by a The thickened lining of the uterus which sperm which normally would support a pregnancy is no longer occurs in the fallopian needed, so it sheds through the vagina tubes During the woman’s period, she The next step for the fertilized egg is to implant into the walls of the uterus, releases a combination of blood, mucus, beginning the initial stages of pregnancy and tissue from the uterus with If fertilization and/or implantation does not take place, the system is assigned associated period symptoms like: to menstruate ○ Cramps The female reproductive anatomy includes parts inside and outside the body ○ Tender breasts which composes the internal and external genitalia or female genitalia ○ Bloating, etc. The function of the external female reproductive structures is twofold: ○ Enables the sperm to enter the body ○ Protect the internal genital organs from the infectious organisms  The follicular phase starts on the 1st day of the woman’s period and ends Problems of the Female Reproductive System when she ovulates A woman's reproductive system is a delicate and complex system in the body ○ It starts when the hypothalamus sends a signal to the pituitary gland It is important to take steps to protect it from infections and injury and prevent to release follicle stimulating hormone (FSH) problems, including some long term health problems ○ FSH stimulates the ovaries to produce around 5 to 20 small sacs Disorders of the female reproductive system can be minor or serious but are called follicles and each follicle contains an immature egg often anxiety producing and distressing ○ The maturing follicles set off a surge in estrogen that thickens the Some disorders or self-limited and cause only minor inconvenience to the lining of the uterus. This creates a nutrient-rich environment for an woman, while others are life-threatening and require immediate attention and embryo to grow long term therapy On the ovulation phase, rising estrogen levels during the follicular phase Many disorders are managed by the patient at home whereas others require triggers the pituitary gland to release luteinizing hormone; this is what starts hospitalization and surgical intervention the process of ovulation Nurses not only need to be knowledgeable about these disorders, but also Ovulation is when the ovary releases a mature egg, and the egg travels down need to be sensitive to patient concerns impossible discomfort in discussing the fallopian tube toward the uterus to be fertilized by the sperm and dealing with these disorders The ovulation phase is the only time in the menstrual cycle when a woman can get pregnant HUMAN PAPILLOMA VIRUS (HPV) INFECTION You can tell that a woman is ovulation by symptoms like: Most common STD on young and sexually active people ○ A slight rise in basal body temperature More than 100 types of HPV exist ○ A thicker discharge that has a texture of egg whites Some are low risk and are unlikely to cause cancerous changes; these Ovulation happens at around day 14 if the woman has a 28-day cycle; it lasts include types 6, 11, 42, 43, 44, 54, 62, 70, and 72 about 24 hrs and after a day, the egg will die or dissolve if it is not fertilized Most common strains: 6 and 11 → condylomata (warty growths) on the In the luteal phase, after the follicle releases its egg, it changes into the vulva corpus luteum ○ Often visible or palpable by patients ○ This structure releases hormones mainly progesterone and some ○ Condylomata are rarely pre malignant for an outward manifestation of estrogen the virus ○ The rising hormones keep the uterine lining thick and ready for a ○ Strains 6 and 11 are also associated with a low risk for cervical cancer fertilized egg to implant High risk oncogenic types: 16, 18, 31, and 45 which affect the cervix causing If the woman gets pregnant, the body will produce human chorionic cell changes or dysplasia gonadotropin (hCG) ○ Cause almost all cases of cervical cancer ○ The hormone pregnancy tests detect The effects of these strains are usually invisible on examination but may be ○ Helps maintain the corpus luteum and keeps the uterine lining thick seen on colposcopy If the woman does not get pregnant, the corpus luteum will shrink away and Incubation period: 2 to 3 months be restored which leads to decreased levels of estrogen and progesterone Incidence: high in young, sexually active women which causes the onset of the woman's period The infection often disappears as a result of an effective immune system During this phase, if the woman does not get pregnant, she will experience response symptoms of PMS (premenstrual syndrome)  It is thought that two proteins produced by high-risk types of HPV interfere with tumor suppression by normal cells Infections can be classified as HPV is caused by a minor trauma during intercourse that can cause Latent or asymptomatic abrasions that allow HPV to enter the body. Epithelial cells infected will ○ Detected only by DNA hybridization tests for HPV proliferate and form a warty growth Subclinical Condylomata acuminata lesions are discrete single or multiple ○ which is visualized only after application of acetic acid followed by inspection under magnification Risk Factors: Clinical Being young ○ where there is visible condylomata acuminata (cauliflower-like lesions) Being sexually active Having multiple sex partners There is a link between HPV and cancer according to this article: Having sex with a partner who has or has had multiple partners ○ However, it can be transmitted by other means as it has been found in young girls who have not been sexually active Signs/symptoms: genital warts Medical management: (treatment of external genital warts): Topical application of trichloroacetic acid Podophyllin (podofin, podocon) → not for pregnant women Cryotherapy Electrocautery and laser therapy → for large number or area of genital warts !! women with HPV should have annual pap smears !! → because there is a potential of HPV to cause dysplasia TOXIC SHOCK SYNDROME - A rare, but potentially life-threatening infection caused by toxin-producing Prevention: strains of Staphylococcus aureus. Routine vaccination of boys and girls 11 or 12 years of age before becoming - Commonly associated with, but not exclusive to the use of super absorbent sexually active (3 doses) tampons. ○ 3 IM doses, initial dose, followed by second dose in 2 months and - Other associations: third dose six months after the first dose Surgical wound infection Use of condoms Non-surgical focal infections ○ Reduce transmission but may occur in areas not cover with condoms Non-menstrual vaginal conditions Faithful relationships Use of diaphragm, cervical cap, and vaginal contraceptive sponge Recent influenza infection Note: Most infections caused by hpv are self-limiting and without symptoms, and Immunocompromised states others can cause cervical and anogenital cancers.  - Signs and symptoms: - Preventive measures for tampon use: High temperature over 38.9 degrees celsius Wash hands before inserting tampon Flu-like symptoms Use the lowest absorbency tampon possible that is still adequate for Vomiting and diarrhea your individual flow. Hypotension Alternate use of tampons with use of sanitary pads. Change tampons Severe muscle pain at least every 4 hours. Decreased platelet count Avoid handling the portion of the tampon that will be inserted Macular (sunburn like) rash; peeling of skin on palms and soles vaginally. Don’t use tampons near the end of a menstrual flow, when excessive Some may have mild diarrhea as a normal accompaniment to dysmenorrhea but vaginal dryness can result from scanty flow. any female who develops fever, diarrhea and vomiting during a menstrual period Don’t insert more than one tampon at a time should suspect TSS and call a physician. Avoid deodorant tampons, deodorant sanitary pads, and feminine hygiene sprays - Therapeutic management: If fever, vomiting or diarrhea occurs during a menstrual period, Penicillinase-resistant antibiotics (cephalosporins, oxacillins, or discontinue tampon use and immediately consult your doctor. clindamycin) Anyone who has one episode of TSS is well advised not to use DOC: vancomycin (for penicillin-allergic patients) tampons again until 2 vaginal cultures to see S. aureus are negative Fluid replacement ○ IV therapy to return circulating fluid volume PELVIC INFLAMMATORY DISEASE (PID) Vasopressors - An inflammatory condition of the pelvic cavity that may begin with cervicitis. ○ Ex. dopamine to increase BP - It may involve the following: ○ Osmotic therapy to shift fluid back into the intravascular Uterus (endometritis) circulation is important to prevent renal and cardiac failures Fallopian tubes (salpingitis) Transfusions Ovaries (oophoritis) ○ To reverse low platelet count Pelvic peritoneum (peritonitis) - Recovery: 7-10 days with adequate therapy but fatigue and weakness may Pelvic vascular system last for months - Common causes: - Preventive measures for diaphragm and cervical cap use: Gonorrheal and chlamydial organisms Wash hand thoroughly with soap and water before insertion or - Exact pathogenesis is not determined but it is presumed that organisms removal usually enter through vagina to the cervical canal, colonize the endocervix Don’t use diaphragm during a menstrual period and move upward into the uterus. Under certain conditions, the organisms Don’t leave a diaphragm in place for longer than 24 hours may proceed to one or both fallopian tubes and ovaries and into the pelvis. Be aware of the s/s of TSS - Bacterial infections occurring after childbirth or abortion, pathogens are - TSS occurs most probably because the organism was not completely disseminated directly through the tissues that support the uterus by way of eliminated from the body. So, adhere to antibiotic prescription and use the the lymphatics and blood vessels lowest absorbency tampon. - In pregnancy, the increased blood supply required by the placenta provides a Ectopic pregnancy wider pathway for infection. Adhesions - Postpartum and post abortion tend to unilateral. Bacteremia with septic shock - Infections can cause perihepatic inflammation when the organism invades the Chronic pelvic and abdominal pain peritoneum. In gonorrheal infections, the gonococci pass through the cervical Recurring PID canal and into the uterus where the environment, especially during Fitz-hugh-curtis syndrome → rare complication that involves liver menstruation, allows them to multiply. capsule inflammation leading to adhesions. - Infection is usually bilateral. - Diagnostic tests: - Risk factors: Pelvic examination Being a sexually active woman younger than 25 years old Endocervical culture of gonorrhea and chlamydia Multiple sexual partners Laparoscopy Being in a sexual relationship with a partner who has more than one Endometrial biopsy sex partner Blood and urine tests Having sex without a condom - Medical management: Douching regularly Broad-spectrum antibiotic therapy Having a history of PID or STI Treatment of sexual partners - Signs and symptoms: Analgesics Abnormal vaginal discharges IVF Dyspareunia Temporary abstinence Lower abdominal pelvic pain - Nursing management: Tenderness occurring after menses Patients must be informed of ectopic pregnancy as a complication of Fever the disease which include shoulder pain, lightheadedness and General malaise abnormal vaginal bleeding. Anorexia Assess the patient for both physical and emotional effects of PID Nausea Prepare the patient for further diagnostic evaluation and surgical Headache intervention as prescribed Vomiting Accurate monitoring of patient’s health status Abnormal uterine bleeding Provide adequate rest Pain may increase with voiding and defecation Encourage healthy diet Intense tenderness may be noted on palpation of uterus or cervix Application of heat to lower abdomen during pelvic examination → cervical motion tenderness Providing symptom relief - Complications: Practice of appropriate infection control Pelvic or generalized peritonitis Abscesses FISTULAS OF THE VAGINA Strictures it is an abnormal opening between two internal organs or between an organ Fallopian tube obstruction and an extension of the body  vaginal fistula ○ is an abnormal opening that connects the vagina to another organ such as the: bladder, colon, or rectum ○ it can be caused by injury, surgery, or an infection Types: ○ vesicovaginal fistula a.k.a = bladder fistula opening between vagina and urinary bladder most common ○ ureterovaginal fistula when the abnormal opening happens between the vagina and the ducts that carry urine from the kidneys to the bladder or the ureters ○ urethrovaginal fistula a.k.a = urethral fistula opening occurs between the vagina and the tube that carries urine out of the body specifically the urethra signs and symptoms: ○ rectovaginal fistula ○ vesicovaginal opening between the vagina and the lower portion of the large urine leaks out of the vagina intestine or the rectum painless, unremitting urinary incontinence Causes: ○ rectovaginal ○ trauma passage of gas, stool, or pus from the vagina ○ may be congenital in origin the combination of fecal discharge with leukorrhea results in ambiguous genitalia in the newborn is often the result of (?) in malodor that is difficult to control the female by adrenal androgens after the time of early ○ other symptoms: gonadal differentiation recurrent vaginal or urinary tract infections, most common type: congenital adrenal hyperplasia or CAH is irritation or pain in the vulva, vagina, and perineum an inherited deficiency of adrenal corticoid hormones pain during sexual intercourse ○ injury during surgery fever ○ radiation treatment diarrhea ○ gynecologic procedures nausea and vomiting ○ bowel diseases like Crohn’s or diverticulitis abdominal pain ○ carcinoma Diagnostic tests: ○ use of methylene blue dye commonly used to help delineate the course of the fistula  in a vesicle vagina fistula, the dye enters the bladder and ○ bladder appears in the vagina ○ vagina ○ indigo carmine (IV) ○ vulva used after a (-) methylene blue test result Risk factors: the appearance of the dye in the vagina indicates ○ familial predisposition ureterovaginal fistula more common in women whose close female relatives are ○ cystoscopy and IV pyelography affected used to determine the exact location ○ shorter menstrual cycle that is less than every 27 days, no longer than Medical Management 7 days ○ GOAL: to eliminate the fistula and to treat infection and ○ flow longer than 7 days excoriation ○ outflow obstruction ○ promote proper nutrition ○ younger age at menarche ○ cleansing douches and enemas ○ young, nulliparous women between 25 - 35 years ○ rest ○ adolescents (dysmenorrhea does not respond to NSAIDS or oral ○ administration of prescribed intestinal antibiotic agents contraceptive agents) ○ low-residue diet (rectovaginal fistula) ○ patients who bear infants late and among those who have fewer ○ cleanliness, frequent sitz bath children ○ deodorizing douches; perineal pads and protective undergarments *in countries with traditions favoring early marriage and early childbearing, ○ meticulous skin care endometriosis is rare ○ application of bland creams Pathophysiology ○ warm perineal irrigations for promotion of wound healing ○ Transplantation theory a backflow of menses called “retrograde menstruation” ENDOMETRIOSIS transports endometrial tissue to ectopic sites through the a presence of a benign lesion/s that contain endometrial tissue that is similar fallopian tube to the lining of the uterus found in the pelvic cavity outside the uterus why some women with retrograde menstruation develop a chronic disease affecting between 6% and 10% of women in reproductive endometriosis and others do not is unkown age ○ Endometrial tissue can also be spread by lymphatic or venous Most common sites: channels ○ ovaries Signs and symptoms: ○ fallopian tubes ○ dysmenorrhea ○ uterosacral ligaments ○ dyspareunia ○ posterior cul-de-sac ○ pelvic discomfort/pain ○ cervix ○ dyschezia or pain with bowel movement ○ abdominal surgery scars ○ radiation of pain to the back or leg ○ rectum ○ infertility may occur due to fibrosis, nutrition, or a variety of ○ intestines substances such as prostaglandins, cytokines and other factors that  may produce by the implants of endometriosis and scar tissue and ○ endo- and electrocoagulation anatomical sites ○ laparotomy these s/s can lead to: ○ abdominal hysterectomy ○ depression ○ oophorectomy ○ loss of work d/t pain ○ salpingo-oophorectomy ○ relationship difficulties Diagnostic tests: UTERINE PROCIDENTIA ○ bimanual pelvic examination or uterine prolapse in which fixed tender modules are sometimes palpated and is the downward displacement of uterine mobility may be limited indicating adhesions uterus in the vaginal canal ○ laparoscopic examination (key diagnostic procedure and helps state 4 stages: the disease stage) ○ stage 1 - the uterus is in stage 1 → pts have superficial or minimal lesions upper half of the vagina stage 2 → mild involvement ○ stage 2 - the uterus has stage 3 → moderate involvement descended nearly to the stage 4 → extensive involvement and dense adhesions with opening of the vagina obliteration of the cul-de-sac ○ stage 3 - the uterus Nursing management: protrudes out of the ○ patient education vagina health teachings about disease conditions and treatments ○ stage 4 - the uterus is involved completely out of the ○ nonpharmacologic mgt for pain vagina (procidentia) ○ pharmacologic therapy (analgesic agents and prostaglandin inhibitors for pain) Causes: NSAIDS ○ persistent high levels of intra-abdominal pressure oral contraceptives ○ pregnancy/childbirth with NSVD effective pain relief and prevent disease progression ○ weakness in the pelvic muscles with advancing age infrequently, s/e will occur with this such as fluid ○ weakening and loss of tissue tone after menopause retention, weight gain and nausea ○ being overweight/obese ○ can be managed by changing brands and ○ major surgery in the pelvic area formulations ○ smoking hormonal therapy signs and symptoms: suppresses endometriosis and relief of dysmenorrhea ○ feeling of something coming out from the vagina Surgical management ○ pressure and urinary problems such as incontinence due to the ○ laparoscopy displacement of the bladder. ○ laser therapy ○ dyspareunia  ○ low back pain VAGINISMUS ○ discomfort upon walking - Involuntary contraction of the muscles at the outlet of the vagina when symptoms may be aggravated when a woman coughs, lift heavy objects, and tampon is inserted or coitus is initiated stands for a long time; even normal activities such as walking up stairs - It could be primary or secondary vaginismus Medical Management: 2 main types: Surgery( or colpocleisis) 1. Primary vaginismus ○ Uterus sutured back into place ○ Also called lifelong vaginismus ○ Strengthen and tightens muscle bands ○ Pain when something enters their vagina including a penis or called ○ Hysterectomy penetrative sex Uterus removed for postmenopausal women ○ Unable to insert anything into their vagina ○ Colpocleisis 2. Secondary Vaginismus Vaginal closure ○ Also called acquired vaginismus Who do not wish to have sexual intercourse or bear children ○ When the woman has had sex without pain before but then it Pessaries becomes difficult or impossible ○ For older women Causes: ○ Those who cannot tolerate Rape surgery Sex viewed as sinful or bad ○ Device placed in the vagina to Anxiety disorders help support the uterus Childbirth injuries, such as vaginal tears ○ Rubber or plastic Prior surgery Pelvic floor muscle training Negative feelings about sex Nursing Management: Signs and symptoms: Early visits to the primary provider Discomfort or pain during vaginal penetration ○ Early detection of problem ○ Like the penis is hitting a wall Kegel exercises Inability to have sex or have a pelvic exam due to vaginal spasms ○ Pelvic muscle exercise Painful intercourse ○ Increase muscle mass and strengthen the muscles that support the Loss of sexual desire uterus Diagnosis: ○ For prevention Medical and sexual history Post op care: Pelvic exam  Confirm presence of muscle spasms Perineal care Treatment: Encourage to void (cystocele and complete tear) - Reduces spasms ○ Within a few hours after surgery Topical therapy Stool softening agents Kegel exercises Position patient with head and knees slightly elevated Vaginal dilator therapy ○ 2 shaped devices  ○ Various sizes Treatment: ○ Stretches the vagina Communication ○ Less sensitive to vaginal penetration ○ Discuss feelings to her partner Cognitive behavioral therapy (CBT) Emotional ○ Helps understand thoughts and behaviors ○ Consider talking to a psychologist ○ Effective therapy for anxiety, depression and PTSD Physical problem Sex therapy ○ Consultation ○ Find pleasure in sexual relationships Taking ginseng, royal jelly, and pollen ○ Effective on certain forms of rigidity FRIGIDITY Vitamin E and zinc - A woman’s lack of sexual interest ○ Corrects functioning of sexual glands - Inability to feel pleasure during sexual intercourse Olive oil, avocado, nuts - Some cases women may experience sexual libido or avoid sexual intimacy ○ Found to increase vaginal moisture Causes: 1. Emotional and psychological CONGENITAL ANOMALIES a. Post traumatic experience IMPERFORATE HYMEN b. Feeling of emotional distance - Thin membrane completely covers the opening of the vagina wherein c. Communication problems menstrual blood flow cannot flow out of the vagina d. Intimacy inhibitors (religious or personal taboos) - Girls can be diagnosed with imperforated hymen at any age e. Feelings of shame or guilt - Diagnosis at birth or later at puberty f. Fear of pregnancy or STD - Healthcare provider may see that there is no opening in the hymen g. Low self-esteem and lack of confidence during a physical exam 2. Physical cause - Girls usually don't have any problems with the condition until they start their a. Pain or discomfort during intercourse period b. Vaginal dryness - Blocks the blood from flowing out c. Lack of adequate foreplay - May occur during embryological development when the hymnal membrane d. Poor male sexual performance doesn’t form properly e. Exhaustion or fatigue Causing: f. Effects of medications, alcohol, substance abuse Mass or fullness in the lower part of the belly g. Changes r/t menopausal/hormonal imbalance Stomach pain h. infection/gynecologic problems Back pain Manifestations: Problems with urinating and bowel movements Feelings of shame Diagnostic Tests: Fear on sexual matters Pelvic exam Painful spasms during intercourse Pelvic ultrasound Emotional detachment - Both ensure that the problem is imperforated hymen Hymen types: - Often a result of virilization in the female by adrenal androgens after the time of early gonadal differentiation Two types 1. True hermaphroditism ○ Having both ovaries and testes and either male or female external genitalia 2. Pseudohermaphroditism ○ Characterized by female internal genitals however, the external genitalia is ambiguous Causes: Treatment: Abnormalities of the Treatment: surgeon makes a small cut or incision and removes the extra chromosomal hymen membrane complement Surgery done early puberty when breast development and pubic hair growth Defects of embryogenesis has begun Biochemical Surgery allows retained menstrual blood to leave the body after, the girl may abnormalities have to insert dilators in the vagina for 15 minutes each day *congenital adrenogenital Later looks like a tampon this skips the incision from closing on itself and hyperplasia(CAH) keeps the vagina open - Inherited deficiency of After the surgery or treatment they will have normal periods already adrenal corticoid hormones Girls can use tampons, have a normal sexual intercourse and can even bear The Prader Scale children - Degrees of genital ambiguity can be described After surgery: - Originally devised to describe degree of virilization of female genitalia in CAH May have to insert dilators for 15 minutes each day Will have normal periods Normal Findings Ambiguous Findings Can use tampons Have normal sexual intercourse -small clitoris at anterior end of labia -enlarged clitoris that protrudes from -urethral meatus located between labia; may be small penis clitoris and vagina -urethral meatus located in clitoris; may AMBIGUOUS GENITALIA -labia minora prominent in newborn but suggest small penis - Uncertain gender is a potential lifetime social tragedy for the child and family. atrophied and almost absent in -prominent labia, partially or completely Furthermore, the electrolyte disturbance says that a company conditions such prepubertal girl; completely separated fused with palpable masses of each as congenital adrenal hyperplasia can be life threatening the identification of from clitoris to posterior vault of vagina side;may be small scrotum with appropriate gender must be done with precision and accuracy -on palpation, no masses in labia - The external genitalia is incomplete or abnormally formed that is impossible to determine the child sex by simple observation Assessment to Determine a Gender Assignment: Therapeutic Management: History - Human growth hormone administration Physical examination - Helps achieve additional height ○ Palpable gonads strongly suggesting a male genotype - Estrogen Therapy ○ Uterus palpable by rectal exam - If done at age 13, secondary sex characteristics can appear and ○ Length of penis stretch to measure location of urethral orifice and prevent osteoperosis location of vaginal orifice - If continued to take every 3 out of 4 weeks, this produces withdrawal Chromosome analysis bleeding that results to menstrual flow. This flow however does not ○ Results are available in two to three days correct the basic problem of sterility. Endoscopy, ultrasonography, and radiographic contrast studies Biochemical tests = However, a woman with Turner ’s syndrome can have IVF surrogate oocyte Laparatomy or gonad biopsy transferring in order to become pregnant Therapeutic Management: *overall goal: to enable the affected child to grow into a well-adjusted, MENSTRUAL DYSFUNCTION psychosocially stable person who is able to identify with the assigned gender and is content with same PREMENSTRUAL SYNDROME Reconstructive surgery - Constitutes to a group of somatic, behavioral, cognitive and mood symptoms Counselling - A combination of symptoms that occur before the menses & subside at the Avoid calling the baby “it” onset of the menstrual flow ○ Say the baby or your child Provide support and encouragement Diagnosis: if symptoms occur during 5 days prior to menses & disappear at the time of menses TURNER’S SYNDROME (45X0) - Gonadal dysgenesis Etiology: not well understood - Child has only a streak ovaries - However, explanations such as sensitivity to serotonin causes a heightened - Child is sterile response to normal cyclic fluctuations of ovarian hormones causing estrogen Manifestations: and progesterone imbalances - Short in stature - Secondary sex characteristics do not Severe Symptoms: PREMENSTRUAL DYSPHORIC DISORDER develop at puberty except for pubic hair SYMPTOMS - Low hairline - Is a condition in which a woman has severe depression symptoms irritability - Webbed and short neck and tension before menstruation. - Stricture of the aorta - May be severely cognitively challenged ! ASSESS FOR SUICIDAL IDEATIONS ! Signs and Symptoms: - Pain occurs several days before menses with ovulation and - Headache occasionally with intercourse - Fatigue - Maybe accompanied by nausea, diarrhea, dizziness, and - Low back pain backache - Breast discomfort Manifestations: - Peripheral edema - Primary - Abdominal bloating - Starts at 12 to 24 hours before the onset of menses - Episodes of binge eating - Pain is most severe on the 1st day of menses (lasts for 2 days) - Irritability - Lower abdominal pain - Mood swings - Radiating to the lower back and upper thighs - Crying spells - Acc. by nausea, diarrhea, or loose stools, fatigue, headache, & Treatment Goal: lightheadedness - Reduce the severity of symptoms - Secondary - Enhances the normal sense of control and quality of life - Pain occurs for several days before menses, with ovulation Non-pharmacological management: - May occur at times other than menstruation - Dietary changes Management: - Exercise - Evaluation to distinguish primary or secondary is through complete health - Stress management assessment and pelvic examination - Education and counseling - Heat application in the lower abdomen or back Pharmacologic Management: - Regular exercise - Symptom specific - NSAIDs, birth control pills - Acupuncture DYSMENORRHEA - Treatment for secondary type: depends on the cause - Abdominal cramping pain or discomfort associated with menstrual flow - Types: AMENORRHEA - Primary Description - Painful menstruation with no identifiable pelvic pathology - Primary - Occurs at a time of menarche or shortly there after - By age 14, has not developed secondary sex characteristics - Characterized by crampy pain occurring before or after the - By age 16 or older has developed secondary sex characteristics but onset of menstrual flow has not started menstruation - Continues for 48 to 72 hours - Secondary - Secondary - Absence of menses for three cycles or 6 months after a normal - Pelvic pathology such as endometriosis, tumors such as menarche leiomyomata or malignancies, polyps, or PID contributes to Causes: symptoms - Primary - Genetic disorders  - Congenital disorders Management: - Malnutrition - Health history and physical examination - Hyperthyroidism - Amenorrhea - birth control pills - Secondary - Menorrhagia - to minimize further blood loss - Pregnancy - Severe Bleeding - hospitalization is required - Breastfeeding - Menopause FACTORS COMPLICATING PREGNANCY - Too little body fat - Eating disorder DIABETES MELLITUS - Thyroid disease - An endocrine disorder in which the pancreas cannot adequate insulin to - PCOS regulate body glucose levels - Excessive exercise Changes in the glucose-insulin regulatory system in pregnancy: - Medications 1. Increased glomerular filtration of glucose with slight glycosuria 2. Increased rate of insulin secretion MENORRHAGIA 3. Insulin resistance develops - Prolonged or excessive bleeding at the time of the regular menstrual flow Risk Factors: - Early: r/t endocrine disturbances Obesity - Later in life: usually results from inflammatory disturbances, tumors of the Age over 25 years uterus, or hormonal imbalance. History of large babies Treatment options: History of unexplained fetal or perinatal loss - Endometrial ablation History of congenital anomalies in previous pregnancies - Myomectomy History of PCOS - Hysterectomy Family history of DM - D&C Ethnicity (Native Americans, Asian, Hispanic) Complications: METRORRAGIA PIH - Vaginal bleeding between regular menstrual periods Hydramnios - Most significant form of menstrual dysfunction Macrosomic babies (>10 lbs) Causes: Congenital anomalies - Menarche and menopause Spontaneous miscarriage - Stress stillbirth - Birth control and medications Risk factors of DM: - Malnourishment  obesity - Fertility treatments  age over 25 years - Underlying health conditions  history of large babies  history of unexplained fetal or perinatal loss   history of congenital anomalies in previous pregnancies diabetes and needs to be confirmed on a subsequent test as soon as  history of PCOS possible, this is usually done using a 75 gram oral glucose challenge  family history of DM test  ethnicity (Native Americans, Asian, Hispanics) ○ for this, after a fasting glucose sample is obtained, the woman drinks Complications: an oral 75 gram glucose solution  PIH ○ a glucose blood sample is then taken for glucose determination at o if a woman has a pre-existing kidney disease, which is revealed by one, two, and three hours later proteinurea, decreased creatinine clearance ang hypertension, the ○ if two of the four blood samples collected for this test are abnormal or risk of hypertension in pregnancy rises markedly or in which the the fasting value is about 95 mg/dL, a diagnosis of diabetes is made condition is called pregnancy-induced hypertension  hydramnios Glycosylated hemoglobin o infants of women with poorly controlled diabetes tend to be large or ○ the measurement of glycosylated hemoglobin is a measure of the more than 10 lbs amount of glucose attached to hemoglobin which is used to detect the  because increase in insulin, the fetus must produce to degree of hyperglycemia present counteract the overload of glucose he or she receives acts as ○ measuring glycosylated hemoglobin is advantageous not just because a growth stimulant it offers a present value of glucose but because it reflects the average o hydramnios may develop because a high glucose concentration blood glucose level over the past four to six weeks causes extra fluid to shifand enlarge the amount of amniotic fluid  macrosomic babies (>10 lbs) Values that confirm Diabetes o a macrosomic infant may create birth problems at the end of the taken on the next three hours after the fasting glucose sample is obtained pregnancy because of cephalopelvic disproportion. this combined with Test type Pregnant Glucose Level (mg/dL) an increased risk for shoulder distocia, may make it necessary for infants of women with diabetes to be born by cesarean birth Fasting 90  congenital anomalies 1 hr 180 o there is also a high incidence of congenital anomaly, especially, caudal regression syndrome — in which failure of the lower 2 hr 155 extremities to develop 3 hr 150  spontaneous miscarriage  stillbirth Diagnostic test: Therapeutic Management: because diabetes is such a serious complication in pregnancy, all women ❖ Proper nutrition should be screened during pregnancy for gestational diabetes 1800 to 2400 caloric diet that is divided into three meals and three ○ a fasting plasma glucose greater than or equal to 126 milligrams per snacks, reduced amounts of fats and cholesterol as well as increased deciliter or non-passing plasma glucose greater than or equal to 200 amount of dietary fiber should be considered milligrams per deciliter meets the threshold for the diagnosis of ❖ Exercise ❖ Insulin  ❖ Blood glucose monitoring ○ as the oxygen saturation of the blood decreases from dysfunction of All women with diabetes need to do blood glucose monitoring to the Alveoli, chemoreceptors stimulate the respiratory center to determine whether hyperglycemia or hypoglycemia exists increase respiratory rate. At first this is this is noticeable only on ❖ Test for placental function and fetal well-being exertion then finally with rest also. as a systemic decrease in blood monitoring of fetal well-being will be individualized depending on the pressure registers on the pressoreceptors in the aorta, the heart rate woman's overall health increases and peripheral vasoconstriction occurs in an attempt to because women with diabetes tend to have infants with a higher than increase the systemic blood pressure normal incidence of birth anomalies, a woman will have a serum alpha ○ as the fall in blood pressure is registered with the renin-angiotensin fetal protein level obtained at 15 to 17 weeks to assess for a neural system retention of both sodium and water occurs tube defect and an ultrasound examination performed at ○ a woman then experiences increased fatigue, weakness, and approximately 18 to 20 weeks to detect gross abnormalities dizziness an ultrasound examination may be taken at week 28 and then again ○ as pulmonary edema becomes severe a woman cannot sleep in any at week 36 to 38 to determine fetal growth, amniotic fluid volume, position except with her chest and head elevated a condition called placental location, and biparietal diameter orthopnea as elevating her chest this way allows fluid to settle to the bottom of her lungs and free space for a gas exchange CARDIOVASCULAR DISEASES ○ she may also notice paroxysmal nocturnal dyspnea which is a for pregnant women with cardiovascular diseases there is an increase in sudden waking at night with shortness of breath this occurs because blood volume and cardiac output, heart palpitations on normal exertion, and heart action is more effective when she is at rest transient murmurs can be heard ○ if mitral stenosis is present it is so difficult for blood to leave the left cardiac disease can affect pregnancy in different ways depending on whether atrium as a secondary problem of thrombus formation can occur from it involves the left or the right side of the heart. non-circulating blood. if coarctation of the aorta is causing the difficulty, dissection of the aorta from high blood pressure from trying LEFT-SIDED HEART FAILURE to push blood past the constriction can occur mitral stenosis Management: mitral insufficiency ○ anticoagulant therapy aortic coarctation to prevent thrombus formation ○ **in these instances the left ventricle cannot move the large volume of ○ antihypertensives blood forward that it has received by the left atrium from the to decrease strain on the aorta, to control bp pulmonary circulation ○ diuretics ○ this causes back pressure the left side of the heart becomes to reduce blood volume distended ○ beta-blockers ○ systemic blood pressure decreases in the face of lower cardiac output to improve ventricular filling and pulmonary hypertension occurs ○ balloon valve angioplasty Manifestations: to loosen mitral valve adhesions and improve valve function ○ pulmonary edema produces profound shortness of breath as it can be performed safely during pregnancy interferes with oxygen carbon dioxide exchange RIGHT-SIDED HEART FAILURE ○ Cause is unknown but this apparently occurs due to stress of Occurs when the right ventricle is overwhelmed by the amount of blood pregnancy in the circulatory system received by the right atrium from the vena cava ○ Mortality rate can be as high as 50% Can be caused by unrepaired congenital heart defects such as pulmonary ○ Manifestation (signs of myocardial failure) valve stenosis Shortness of breath Eisenmenger syndrome Cardiomegaly Most common cause of right sided heart failure in women of reproductive age Chest pain Right to left atrial ventricular septal defect with an accompanying pulmonary Non-dependent edema valve stenosis ○ Management There is congestion of the systemic venous circulation and decreased cardiac Reduce shortly physical activity output to the lungs Diuretics Blood pressure decreases in the aorta because less blood is able to reach it Arrhythmia agent Pressure is high in the vena cava from back pressure of blood Digitalis therapy Manifestations: Low molecular weight heparin (?) - decreases risk of ○ Jugular venous distension and increased portal circulation are evident thromboembolism ○ Liver and spleen become distended Nursing management for women with cardiovascular disease: Extreme liver enlargement can cause dyspnea and pain to Promote rest (2 rest periods and full night sleep) pregnant women because the enlarged liver is pressed Promote healthy nutrition upward by the enlarged uterus puting extreme pressure to the Educate regarding medications diaphragm Educate regarding avoidance of infection ○ Ascites and peripheral edema Caused by distension of the abdominal and lower extremity URINARY TRACT INFECTION vessels which leads to exudate of fluid from the vessels into In pregnant women ureters dilate from the effect of progesterone → stasis of the peritoneal cavity urine Management: Minimal glycosuria that also occurs in pregnant women provides as an ideal ○ Diuretics medium of growth for any organisms present ○ Vasodilators Causative agent ○ Beta-blockers ○ Escherirchia coli (E.coli) ○ Digoxin Manifestations: ○ Pulmonary vasodilators ○ Urinary frequency ○ Pain in urination PERIPARTUM HEART DISEASE Both urine frequency and pain in urination are the typical Peripartal cardiomyopathy manifestation of UTI ○ Extremely rare condition that can originate in pregnancy of women ○ Pain in lumbar region with no previous heart disease Pyelonephritis Pain usually on the right side, radiating downward  Tender to palpation MULTIPLE GESTATION May be accompanied by malaise, pain, frequency of urination Complication of pregnancy because the body would need to adjust for the and nausea and vomiting effects of more than one fetus ○ Fever Twins: Infection usually occurs on the right side because there is greater ○ Identical  Single ovum and single spermatozoa compression and urinary stasis on the right ureter from the uterus being ○ Fraternal  Separate ovum and spermatozoa pushed by the large bulk of intestine on the left side Manifestations: Diagnostic test ○ Uterus begins to increase in size at a rate faster than usual ○ Clean catch urine sample for culture and sensitivity test ○ Elevated alpha-fetoprotein level To assess for asymptomatic bacteria or symptoms of UTI ○ At the time of quickening woman will report flurries of action at Sensitivity test different portions of her abdomen rather than at one consistent spot To determine which antibiotic best combats the ○ Multiple sets of fetal heart sounds infection If one or more fetus has her back positioned towards the Management woman’s back, only one fetal heart sound may be heard ○ Amoxicillin, ampicillin, cephalosporins Complications Effective among most organisms causing UTI and are safe ○ Pregnancy induced hypertension during pregnancy ○ Hydramnios TETRACYCLINE IS CONTRAINDICATED (cause ○ Placenta previa retardation of brown growth and staining of deciduous ○ Preterm labor teeth) ○ Anemia ○ Increase fluid intake (3-4L/day) ○ Postpartum bleeding To flush out infection from the urinary tract ○ Low-birth weight To be most effective give the client a specific amount to drink Management everyday to make certain that she has increased her fluid ○ Bedrest intake Side-lying position to increase placental perfusion ○ Knee-chest position for 15 minutes ○ 6 small meals/day Do this morning and evening Due to the growing uterus pressing into the stomach it may Promote urine drainage cause her appetite to decrease and to compensate have 6 The weight of the uterus is shifted forward, releasing pressure small meals instead of 3 large ones on the ureters and allowing urine to drain more freely ○ Iron, folic acid, vitamin supplement ○ Encourage medication compliance ○ Provide support to the mother Prevention: A women with multiple pregnancy has to work through an ○ Voiding frequently additional role change during pregnancy which takes time and ○ Wiping front to back may be difficult to complete especially if pregnancy ends early ○ Wear cotton underwear Extra help after birth to form a close mother relationship with ○ Voiding completely after intercourse the newborn