AP/PP Module 2 Exam Blueprint PDF

Appp Module 2 Exam Blueprint bi Kimberly Cobb madeleine Cain Unit 6: Health education during pregnancy 1.Review smoking and marijuana use in pregnancy Midwifery Approach: Ask, Tell, Listen Screening for substance use is recom...

Appp Module 2 Exam Blueprint bi Kimberly Cobb madeleine Cain Unit 6: Health education during pregnancy 1.Review smoking and marijuana use in pregnancy Midwifery Approach: Ask, Tell, Listen Screening for substance use is recommended for all individuals early in pregnancy. ACOG recommends universal screening, brief interventions, referral for treatment for all misuse of substances. Care of those in need of help required collaboration with professional in multidisciplinary programs who have the skills in treating substance misuse/addictions. Team based care improves the persons health and experience of care. Concerns about the fetus could be the catalyst incite a change in a person improving both short and long term effects. Tobacco: Aprox. 1 in 14 pregnant pts smoke Risk: Ectopic pregnancy, SAB, placental Cannabis: dysfunction, FGR, low birth wt., SIDS 45% stop smoking while pregnant (harder to Most common after stop when pregnant because of the increased tobacco and ETOH metabolism of nicotine in pregnancy) Crosses the placenta Cessation plans include: nicotine gum, No true evidence of patches, lozenges, and e-cigarettes and they harm to the fetus are available without a prescription and safe for Recommendations is to pregnancy. stop use in pregnancy 5 A’s program shows success in quitting and during smoking breastfeeding even Not much evidence but the evidence that when there is a exists shows no correlation with vaping and prescription for it. fetal growth restriction. Medications: bupropion or varenicline  2. Know health education and recommendations related to iron supplementation in pregnancy Iron Supplementation: Supplements: For treatment of Heme Non-Heme iron-deficiency Anemia y -Found in animal products -Found in legumes, dark -First line: Ferrous salts 30-100mg of and more efficiently leafy greens, nuts, seeds, elemental iron generally increases absorbed (20-30%) whole grains, and dried retic count within 2 weeks fruits, less efficiently -Vit C. Increased absorbed (2-10%) -Separate other multivitamins from absorbtion the intake of iron to maximize -Vit c does not increase absorption -When trying to increase absorption -If SE suck take 120mg elemental through food intake avoid iron 1-3 times weekly to decrease antacids two hours before SE. SE are proportional to the dose, and 4 hours after ingestion. could do less amount over the day as an option too. -Enteric coated or slow release option decrease absorbtion in the small intestine avoid this. Higher risk for Iron Deficiency Anemia: -Pregnant people with risk increasing with multiples, adolescent age, non-Hispanic black, Pregnancy and Iron Needs: and vegetarians. -Iron needs double in pregnancy -Malabsorption conditions: IBS, Bariatric -Iron absorption increases with increased gest surgery age. -Menstruating women (esp heavy flow) -Iron supp. Increases plasma hemoglobin levels but does not affect overall maternal/neonatal -Short interval pregnancies outcomes unless specifically treating iron deficiency anemia during pregnancy. -Situations resulting in iron loss in from intestines daily: H. Pylori, malaria, intestinal -Absorption of iron in PNV depends on the amount parasites of calcium in the vitamin. -Intermittent Iron supplementation is suggested given the limit for iron stores and might absorb it best if intestine is not constantly exposed to it. 3. Know the food safety recommendations in pregnancy 4. Know about vaccine safety and recommendations for administration in pregnancy Immunizations: IgG antibodies cross the placenta providing passive immunity Vaccines composed of inactive antigen or toxoid are save in pregnancy Live-attenuated vaccines are not considered safe in pregnancy Ideal times of the TDAP is 27-36 weeks on the earlier side of that is recommended. Annual flu vaccine is reccomeded in any trimester ideally by the end of October For those at risk hepatitis A/B and meningococcal are reccomended Address questions thoughtfully and maintain respect for person decisions related to vaccination Black people typically are least likely to be offered standard vaccines. Infection/Disease: Can cause serious/life- threatening illness when pregnant and can harm the fetus or neonate. Flu, COVID-19, and varicella are associated with increased risk of maternal deaths Listeriosis, parvo, rubella, syphillis, varicella, cytomegalovirus, and toxoplasmosis can harm the fetus Zika is associated with congenital microcephaly. Herpes and GBS can harm the newborn during vaginal birth 5. Discuss exercise guidelines and cautions in pregnancy. Dr. Faucher slides Reccomended 150 minutes a week of moderate exercise Few contraindications: cerclage-PTL, placenta previa, poorly controlled DM, multi fetal gestation, significant CV disease or pulmonary disease. Varneys (page 856): All pregnant women engage in 30 minutes of moderate physical activity, including aerobic exercise and strength training, almost everyday, fora total of 150 minutes/week Best modalities are walking, swimming, water aerobics, stationary cycling, dancing, strength training with resistance (weights/bands), and yoga. Avoid prolonged exercise in the heat and stay hydrated Walking is generally the most sustainable form of exercise in pregnancy Encourage activities that the pt will enjoy to increase compliance throughout pregnancy No limitations mentioned Williams (page 187): The tale of two studies: Both placenta size and birthweight are significantly greater in women who exercise during pregnancy. Working women who exercise halve smaller neonates and more dysfunctional labors. Avoid activities with a high risk of falling or abdominal trauma. No scuba diving because risk of fetal decompression sickness. Contraindications: -significant CV or pulm, diseases: chest pain, calf pain, or swelling -Significant risk for preterm labor: cerclage, multi fetal gestation, significant bleeding, threatened preterm labor, ruptured membranes -OB complications: pre e, placenta previa, anemia, poorly controlled diabetes or epilepsy, morbid obesity, fetal growth restriction 6. Provide counseling related to supplementation in different populations such as those with a history of gastric bypass and vegetarians. Dr. Faucher slides: Vitamin B12 deficiency: (risk for NTD) risk in vegetarians, high consumptions of vitamin. C, post Roux ne Y bariatric surgery. Vitamin B6: May help with N/V Vitamin D (deficiency common): Low exposure to sunlight, vegetarians, ethnic minorities Iron: Obesity and twin gestation increases iron demands, short interval pregnancy, vegetarian. Folic Acid: increased amount if increased risk of NTD Mg: risk in pts with gastric bypass Zinc: risk for deficiency in vegetarians (RDI 12 mg) Roux en Y - B12 injections q 3 months - Vitamin D: 1,000 IU -Folate: 0.4ug/day or higher if BMI still in the obese categories -Thiamine 300mg.day and B-complex supplementation q day with NV  7. Provide gestational weight gain counseling by week and across pregnancy A relationship exists between both Increased caloric intake in pregnancy insufficient and excess gestational wt gain. 1st trimester: 200 cal 2nd Trimester: 300 Cal Inadequate wt. gain: low birth wt, SGA, preterm 3th Trimester: 400 cal birth, increased perinatal mortality, and long term Adverse epigenetic effects occur in the presence of both over and under nutrition, the high glucose increased risk for obesity and DM. levels seen with diabetes and pregnancy, oxidative Excessive wt. gain: c/s birth, postpartum wt stress, and lack of key substrates such as fatty acids. retention, and decreased lactation success. Long term outcomes can include metabolic syndrome, DM Recommended wt gain in pregnancy is II, and cardiovascular disorders. correlated to the pregestational BMI UNIT 7: Common discomforts of pregnancy 1. Benign discomforts of pregnancy vs pathological conditions Cardiovascular/Respiratory strategies : small frequent meals and sitting - , -empression socks - avoid simple carbs csub whole grains Musculoskeletal from ppt) strategies cont ) wh heat. not - topical analgesics OK (cust -low comfortable shoes - Lavendar and chamomile avoid high phosphorus /low calcium foods. - Isodas , processed foods) - daily exercise : Walking or swimming -keeplegs War ted musure - calcium supplementation increase Foods rich calcium mag , and - un + , conti strategies - +incture of time. ??? - sun exposure piriformis stretches - Gastrointestinal conti Strategies foods that stimulate bowels - : colace 100mg Q HS - prunes prune Juice , coffee , · , not drinks , mangos , papaya , dandelich rost - avoid bananas , carb intake - corrective: massage abdomen in clockwise Fashion , acupuncture strategies cont: & pobiotics peppermint candy - Fresh, juiced, cooked - -do not suddenly-parsley - ↑ Fiber avoid unions beans lentils, - , , collard greens , cauliflower try brussel sprouts ,cabbage or turnips - - sit or stand after eating try Papaya - , back slippery elm lozenges , rour - half a lemon in cost water or top of raw apple rider Vinegar amonds , anise , Fennel seed teal order of treatment : - preparation #, phenylephrine , Promoxine or diplaine suntment. -comfrey sitment yellow dock rost , plantain and yarew sitment outment ,. - vorticone sitment / from is last resort peppermint raspberry leaf - , Cyerba buena , gingerer chamomile tea. - gunger dose : 250 QID - sour candies , mints my trangellemon citrus Fruit and pickles - - rind in ziplock bug -anise or fennel seed upon warnung Reproductive/Urinary · ↓ sexual stimuli until Tenderness subsides · eliminate Caffeine. Other · more common in + 3rd trimesters and - , in older primes wi generalized edema ↓ Suity sugar intake & Fluids , · stretching/wrist exterision (Frm yoga) 2. What are both pharmacological and non-pharmacological treatments for common gastrointestinal discomforts experienced in pregnancy such as heartburn, nausea, and constipation. Know first like treatments and first line medications. Constipation Heartburn NonPharmocologic: Non-Pharmocologic: Change diet/increase fluids Small frequent meals Warm liquid before drinking to stimulate Avoid fatty/spicy food peristalsis Sit or stand after eating Exercise regularly Avoid tight fitting garments in Consume foods constraining roughage, midsection bulk, and natural fiber Sleep with head elevated Pharmocologic: Half a lemon in cool water or teaspoon Mild bulk-forming laxatives, stool of raw cider vinegar softeners, and glycerin suppositories Pharmocologic: Begin with antacids then move as necessary to H2 receptor antagonists and lastly to PPI Nausea Nonparhmacologic: Small frequent meals Avoid foods with strong odor or fried/ fatty foods Temporarily discontinue PNV but continue with folate supplementation. Ginger Accupresure bands Vitamin B6 Pharmacologic: Mild add: B6+Doxylamine Benadryl Prochlorperazine Pomethazine Moderate Diclegis Promethazine Metoclopramide Ondansetron 3. How can leg cramps, sciatica, and back pain by managed?  Unit 8 1. Know critical levels of hcG during first 10 weeks of pregnancy hCG increases 49 -66% every 48 hours-Faucher study guide old adage that beta doubles every 48 hours Initial value less than 1500: doubles 49% every 48 hours Initial value been 1500-3000: rise by 40% Initial value greater than 3000: rise by 33% Varneys pg 888 2. Know progesterone levels in viable pregnancies during the first 8 weeks of pregnancy Faucher study guide Progesterone less than 5-6ng/mL suggests a dying pregnancy; levels greater than 20ng/mL support the dx of a healthy pregnancy Progesterone does not aid in determining the site of the pregnancy 3. Recognize the signs & symptoms of threatened ab, inevitable ab, missed ab, and management protocols Threatened: Painless vaginal Inevitable: 2 weeks after an US showed a gest sac without yolk sac or > 11 days after US showed a gest sac with a yolk sac. Expectant management: First line management, but has the lowest effective rate and is simply watchful waiting for POC to pass on their own. Within 4 weeks of diagnosis 90% of pts will spontaneously pass POC following an incomplete SAB. Only 66% of pts will pass products with an embryonic gestation and 76% for embryonic demises. Follow-up is important and counseling should be provided regarding an agreed upon timing to for POC to pass. This might not be a good choice for those with limited transportation availability or a busy lifestyle. Pt should call provider for any signs of infection and strict heavy bleeding precautions should be provided for return to the ER. Medication Management: Prescription for misoprostol or combo of misoprostol and mifepristone to expedite the passing of POC. Precautions provided to the pt are the same as expectant management in regards to bleeding/ infection. Chance for fever for 24 hours following misoprostol. Pts need to know that this is not 100% effective could still lead to surgical management. Follow up: Surgical Management: Options 1.Abstain from vaginal intercourse for 2 weeks. include a manual vacuum-aspiration or D&C to remove the failed 2. F/U: 1-2 weeks after passage of tissue with bHCG redrawand if pregnancy. This is the management of elevated repeated until they reach 5.With recurrent SAB evaluation for congenital abnormalities of genital tract should be considered,as well as genetic 6. Rhogam within 72 hours of testing, and tests for coagulation disorders/thyroid completed SAB abnormalities. 4. Interpret findings on US to determine if the pregnancy is viable or if there is a threatened abortion 5. Identify the signs of ectopic pregnancy Signs/Symtoms: Diagnosis: Serial HCG levels: slower rise with Bleeding/irrregualr spotting ectopic or could show declining Sudden sharp, stabbing pain unilaterally in values. lower abdomen (when combined with hypotension and shock probably rupture) US Findings: ring of fire, pseudo sac, Tender abdomen hypoechenic with trasnvaginal US Painful vaginal exam (PPV-80%) Cervical Motion Tenderness No gest sac in uterus with hCG levels Poss adnexal mass (shouldn’t be > 2000 (discrimination zone) palpating b/c could aide in rupture) Post. Vaginal fornix bulging Pain in neck/shoulder esp during inspiration from diaphragmatic irritation fro blood in peritoneal cavity. 6. Identify treatment for ectopic pregnancy Tania Lopez Lecture: *Management of Ectopic pregnancy is not within the CNM scope of practice, but CNM must be able to recognize the potential that there is an ectopic pregnancy* Expectant management Only if HCG levels continue to decline and the pt is stable Medical Management Methotrexate: Folate antagonist that inhibits DNA synthesis and cell replication-considered chemotherapeutic medication, and only approved medical management for ectopic. Purpose is to dissolve the pregnancy to prevent rupture Increased surveillance is required (office visits, lab draws USs) Treatment success is 70-95% Risk factors/contraindications to discuss with pt prior to using immunodeficiency, thrombocytopenia, IUP, severe anemia, pulmonary disease, peptic ulcer disease, and hepatic dysfunction. Relative contraindication if fetus has cardiac activity, is greater than 4 cm, or if really high HCG over 5000, or if pt refusing blood transfusion. Pt must also be stable, and mass unruptured Pt must understand the extensive follow-up involved with choosing this management Order CMP before starting to assess kidney/liver function 50mg/m2 on day one, check HCG on day 4 and 7. If HCG level does not decrease at least 15% from day 4 to day 7 then it can be associated with high risk of treatment failure so consider another dose or moving to surgical intervention. SE: GI symptoms Avoid sunlight to decrease incidence of dermatitis, stop taking PNV will combat treatment, avoid pregnancy for 1 ovulatory cycle consider birth control after successful treatment for 3 months to ensure methotrexate is out of system. Educate to report increased pain, fever, or bleeding Check ABO/RH status, give Rhogam if indicated Emotional care-pregnancy loss, talk about future fertility counseling. Surgical Must if pt is unstable otherwise medical and surgical approach are viewed as both acceptable Consider this first if pt is looking for permanent sterilization along with treatment. Varneys (page 889) Establish physician care Medical: Methotrexate oral or IM if pt is stable Consider repeat dose or move to surgical management if not effective. Surgical: Safe and effective as first or second line intervention  7. Compare and contrast treatment for incomplete AB Definition: Passage of some fetal or placental tissue through the cervix at less that 20 weeks gestation-tissue is visible in the uterus without evidence of viable gestation. Expanctant management If pt is stable this is typically the first line treatment Medical Mangement: Watchful waiting for products of conception Pt must be stable to pass on their own Combination of miso and mifepristone to Lowest effectiveness of all options-90% of facilitate an expedited process of passing all pts will spontaneously pass everything by 4 products can be administered up to 84 days weeks time for an incomplete AB. Counseling should include an agreed upon or 12 weeks gestational age time for products to pass on their own at Strict bleeding precautions should be which time a second option should be provided discussed. Typically 95% effective Might not be the best option for people with Mifepristone is given once in clinic setting a busy schedule, limited access to followed by 1-2 doses of miso 800cg transportation, or limited social support. vaginally or bucally (increased SE) 24/48 Instructions should be provided to contact hours later. Miso dose may be repeated the HCP for fever, chills, body aches, foul once 12-24 hours after initial dose. smelling vaginal discharge, and strict bleeding precautions provided. Pt should be advise of possible need for NSAIDS or low dose opioids can be offered surgical management with failed medical for pain management. management. Consider genetic studies for two or more consecutive losses In person follow-up is typically 7-14 days after passage of POC and HCG trended down to = 7mm AND lack of Tissue visible in the uterus without cardiac motion evidence of viable gestation. Absence of embryo with heartbeat >= 2 weeks after an US showed a gestational sac without a yolk sac or >= 11 days after US showed a gestational sac with a yolk sac. 9. Know the characteristics of a hydadiform mole. Varneys (page 890): Develops following a messed union of egg and sperm, no or limited fetal tissue develops just a lot of abnormal trophoblastic tissue that fills the uterine space. Characteristics: Placenta villi become edematous and on US this will have a grape-like, honey-comb, or snow storm appearance. Symtoms include abnormal bleeding, uterine size greater than dates, absent fetal heart tones, hyperemesis, hyperthyroid symptoms, cystic enlargement of the ovaries, HTNin 1st trimester without previous HTN, and abnormally high beta-HCG levels. Risk factors for molar pregnancy: age under 16 or over 40 Previous molar pregnancy Tanias Lecture: Highest risk factor is previous molar pregnnacy so subsequent pregnnacy should be followed closing with serial HCG and US. Most common in south Asians, Hispanics, and native Americans. Clinical presentation: Hyperthyroid, hyperemesis, HTN, large uterus, theca-luteum cysts on ovaries on US. Lesions can move to lungs causing coughing and hemoptysis because lesions can move to lungs. Can be malignant. Consider Chest x-ray. Never use cervical ripening or any contracting agent because contractions can lead to trophoblastic embolism. Monitor HCG weekly until undetectable, can take months. Do not get pregnant for 6 months following HCG < 5. IUD? Most important thing is to recognize early to reduce chance of metastisis. 10. Discuss Etiologic factors of recurrent miscarriage Dr. Fauchers study guide for recurrent miscarriage The etiology of recurrent loss is identified in 50% of the patients Medical evaluation is recommended after 2 first trimester losses (some resources say 3) Possible causes Genetic errors: genetic testing of POC with SNO microarray. However if this is the reason it needs to be discussed with pt that there might be an inability to achieve a healthy pregnancy Structural malformations: septate uterus has highest association of RPL Clotting disorders Medical Conditions: Thyroid disorders, APS, Hyperprolactinemia, DM, PCOS, Obesity More than 1/2 of pregnancy loss is due to random cytogenetic errors (how chromosomes relate to cell behavior) Male factors: Sperm defragmentation, no viable intervention is available. Infections: colonization of chorion and decidua with urea plasma urealyticulum or mycoplasma hominis. ETOH/Tobacco/Caffeine: Dose dependent relationship to RLP.  Unit 9 1. How would fibroids affect pregnancy Varneys page 924 uterine anomalies such as bicornuate uterus or presence of large fibroids in the lower uterine segment impede a normal vertex presentation—>increased risk for breech presentation Can cause first trimester bleeding 2. How might bicornuate uterus or a uterine septum affect pregnancy? Bicornuate uterus Uterine septum recurrent miscarriage associated with infertility Fetal growth restriction Recurrent miscarriage Preterm labor/birth Placenta acreta (if Malposition septum was resected) placental abruption 3. How is placenta previa diagnosed? At what gestational age? What is the management? Diagnosed by US 2% of pregnancies will have a placenta previas identified during second trimester anatomy US 90% of these placentas will no longer be located over the cervical os later in pregnancy as the placenta growth towards the fundus Management Once diagnoses: instructed to call or be evaluated if vaginal bleeding occurs. Repeat US at 32 weeks to determine placental location and then again at 36 weeks Vaginal birth an option with low lying placental however increase risk of PPH If placental edge remains over the cervix or within 1cm of internal os—vaginal delivery is contraindicated—c/s scheduled at 36-37 weeks OB referral is indicated for a person with persistent placenta previa Avoid sex with orgasm (aww) or vaginal penetration (double aww) —to avoid uterine contractions or direct trauma to cervix 4. Define placenta acreta. What are the risk factors? Defined as: Placenta accreta spectrum is an abnormality of placental implantation in which the anchoring placental villi attach to the myometrium instead if to the decidua in the endometrium; occurs when placenta implants over an area of the uterus that is scarred or damaged Placenta accreta: when the cytotrophoblast attached to the myometrium Placenta increta: when the cytotrophoblast invaded the myometrium Placenta percreta: when the cytotrophoblast extended through through the myometrium and the serosa, attaching to adjacent pelvic organs In current practice Placenta Accreta spectrum is used any any degree of placenta accreta to reinforce the understanding that the level of perinatal care needed for management is similar for all presentations Risk factors: previous c section Uterine procedures associated with assistive reproductive technology (myomectomy or resection of uterine septum) More common with placenta previa Anterior low lying placenta in a person with a history of c/s 5. Define low birth weight vs SGA and macrosomia vs LGA SGA: describes a newborn who is below Macrosomia: term used to describe the 10th percentile in wt for its gestational a baby that is 4000-4500 grams age and should not be used as a term until regardless of gestational age and can the baby is born and weighed only be called so once the baby is born and weight, prior to that the term is suspected macrosomia. LGA: a fetus whose estimated weight is greater than the 90% in relation to gestational age. LGA diagnosis becomes more significant with the presence of diabetes. In diabetes the baby gains more body fat centered around the shoulders and chest leading to an increased risk for shoulder dystocia or birth trauma. FGR: diagnosed when estimated weight or abdominal circumference is less than the 10% for its gestational age. Early onset: strongly associated with progressive growth, restriction, demonstrated by decreasing growth percentile across successive ultrasounds. Late Onset: associated with less severe growth, restriction, lower incidence of abnormal doppler flow during pregnancy, and fewer findings on placental pathology after birth 6. What is asymmetric fetal growth restriction vs symmetric fetal restriction? What etiology or conditions are associated with each? What is the management? Asymmetric Def: Category of FGR where the fetus Symmetric estimated weight or abdominal Def: Both the fetus body and head are below circumference is below the 10%, but its the 10%. had circumference is larger than the 10%. Etiology: Most common cause that results from Etiology: anything that causes decreased early pregnancy are from congenital anomalies. Other blood flow or decreased oxygenation to the causes are maternal severe malnutrition, low pre- fetus causing the fetus to preserve the pregnnacy wt, no wt gain, muiltfetal gestation, brain over the rest of the body. HTN, Renal perinatal infections, and exposure to drugs or disease, Diabetes, heart disease, environmental teratogens. Bariatric surgery. hemoglobinapathies, and severe asthma. Management: Growth should be monitored with Management: idk how the management serial US every 3-4 weeks; NST and BPP should not be would change, I suppose considering the completed before a gestational age when delivery would severity, threshold for delivery would be be considered. Serial umbilical artery assessment should small with any added maternal or fetal be performed to assess for deterioration. Steroids should problems like oligo, or worsening HTN. be given if 10th percentile — HTN, renal disease, DM, heart disease, hemoglobinopathies, and severe asthma Severe growth restriction: EFW at or < 3%. Increased risk of morbidity and mortality, stillbirth, abnormal Doppler findings. Onset: Early onset: prior to 32 weeks. Progressive growth restriction, severe placental dysfunction (abnormal Doppler), abnormal placental pathologies after birth, genetic anomaly in fetus or maternal HTN Late onset: after 32 weeks gestation. Associated with less severe growth restoration, lower incidence of abnormal Doppler findings and few placental pathology findings. Represents 70-80% of FGR. incidence: higher in pathological conditions 6. The guidelines managing Preterm-PPROM