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Intimate partner violence (IPV)•Physical or emotional abuse
•Sexual assault
•Isolation
•Controlling all aspects of the woman's life: Money, Shelter, Time, FoodCycle of violencePhase 1: Tension building
•That her experiences increased tension, victim minimizes problems
•Tension becomes intolerable
Phase 2: Abusive incident
•Batterer highly abusive, incident occurs
Phase 3: Honeymoon period
•Loving, apologetic, promises changeBattering during pregnancy•Rates range from 4% to 8% and may be as high as 20% in some populations
•Incidence of intimate partner violence may escalate
•May happen for the first time during pregnancy
•Risk to the fetus includes increased rate of miscarriage, preterm birth, and stillbirthMenstrual Cycle: Three CyclesHypothalamic Pituitary Axis:
•GnRH
•FSH
•LH: stimulates ovulation
Ovarian Cycle:
•Follicular Phase: first, day 1 of period until day 14
•Luteal Phase: after ovulation occurs and lasts until period starts again. corpus luteum involved in this phase
Endometrial Cycle:
•Menstrual Phase: get period
•Proliferative Phase: estrogen causes endometrial growth
•Secretory Phase: progesterone causes thinker endometrial tissue, thickening the vasculature
•Ischemic Phase: if no sperm fertilizes the egg, uterine lining thins off and period startsAmenorrhea = Absence of menstrual flowPrimary-
•Absence of menarche by age 13 OR absence of menses by age 15 with normal growth & development.
Secondary-
•Absence of menstruation within 5 years of breast development OR
•Six months without menses which had occurred before.
Treat:
-Ca & Vit D supplements may be given
-Oral contraceptives in some circumstances: gives body a hormone cycle.Hypogonadotropic Amenorrhea•Absence of menstrual flow due to problem in the hypothalamic pituitary axis.
Etiology:
•Pituitary lesion or genetic inability to produce FSH/LH (rare)
•More common: stress, sudden weight loss, eating disorders, excessive exercise.Dysmenorrhea•Pain during or shortly before menstruation
•Primary dysmenorrhea: Associated with ovulatory cycles
•Etiology: Prostaglandin F₂ alpha causes uterine contractions & vasospasm of uterine arterioles. This results in cramping and ischemia
•pain starts with period and lasts 12-72 hours
•secondary dysmenorrhea: later onset after 25, associated with adenomyosis, PID, fibroids
-treat: heat, aerobic exercise, relaxation breathing biofeedback, yoga, diet, NSAIDS, oral contraceptionPremenstrual Syndrome (PMS)•Luteal phase onset with symptom free period after.
•Ovarian function is required
•Over 150 physical/psychological symptoms
•All age groups affected.Premenstrual Dysphoric Disorder (PMDD)•More severe variant of premenstrual syndrome.
•Marked irritability, dysphoria, mood lability, anxiety, fatigue, appetite changes, feelings of being overwhelmed.Premenstrual Syndrome and Premenstrual Dysphoric Disorder management•Detailed history, physical and log of symptoms
•Education and listening
•Diet: reduce salt, sugar, caffeine, red meat. Increase whole foods.
•Exercise: 60 mins daily
•Natural diuretics: asparagus, cranberry juice, peaches, parsley, watermelon.
•Calcium & Vitamin D, evening primrose oil, chasteberry (Table 4.2) for some women.
•Support groups/counseling
•NSAIDS, progesterone, oral contraceptives (OCP's), SSRI's,Endometriosis•Presence and growth of endometrial tissue outside of uterus
•Tissue responds to hormonal stimulation in the same way that endometrial tissue responds.
•Typically occurs in third or fourth decade of life.
•30-45% of infertile women suffer.
Etiology:
•Not well understood
•Transplantation or retrograde menstruation from fallopian tubes (back flow during period)
s/sx:
•pain: dysmenorrhea and dyspareunia (pain during sex), pain during exercise, often chronic condition with pain and infertility
Management:
•NSAIDs and oral contraception
•For more severe symptoms: Suppression of endogenous estrogen:
•GnRH agonists (leuprolide): go to treatment; may be used if in pain
•Androgen derivatives (Danazol)
•OR Surgery (TAH & BSO)Leiomyomas (fibroids or myomas)•Benign tumor that originates from the smooth muscle of the uterus
•Can be asymptomatic or cause menorrhagia
•Etiology: Unknown.
•Signs and Symptoms: menorrhagia, dysmenorrhea
Management:
•Medication to shrink tumor (GnRH agonist)
•Surgically- myomectomy or hysterectomyOligomenorrhea•Infrequent menses every 45-50 days
•Etiology- pituitary tumor, excessive exercise, low BMI, Polycystic ovarian syndrome, perimenopauseHypomenorrhea•Scant bleed, normal interval
•Etiology- similar as Oligomenorrhea (pituitary tumor, excessive exercise, low BMI, Polycystic ovarian syndrome, perimenopause)Metrorrhagia•Intermenstrual bleed
•Etiology- pregnancy, endometriosis, fibroids, & cancerMenorrhagia (hypermenorrhea)•Excessive menstrual bleed (duration or amount)
•Etiology- fibroids, malignancy, polyps, Paraguard IUD (non hormonal IUD)Menometrorrhagia•Excessive menstrual bleed which is irregular & frequent
•Etiology- adenomyosis, fibroidsAbnormal uterine bleeding vs. Dysfunctional Uterine Bleeding (DUB)•Irregular in amount, duration or timing. DUB is bleeding which occurs in the absence of organic causes
•Etiology- Associated with anovulatory cycles & conditions causing continuous estrogen production such as obesity, hyperthyroidism, hypothyroidism, PCOS.
•DUB Management- History, physical, counseling & education; hormonal therapies (estrogen/progestins), D&C, ablation (Novasure), hospitalize prn, transfusion, endometrial bipopsy.Fibrocystic Breasts-•benign breast changes characterized by small cysts
•Etiology: Unknown; thought to be related to estrogen excess/progesterone deficiency in luteal phase.
•Symptoms: Cyclical-develop one week before menses and lasting 1 week after end of menses. More common in younger women.
•Detection: Exam, ultrasound, aspiration, fine needle aspiration.
•Management: conservative, high quality diet, avoid methylxanthines, decreased ETOH & smoking, mild diuretics, OCP's, heat or cold packs, Vitamin E or primrose oil.Breast Screening Guidelines-Mammography: Every year beginning at age 40.
-Clinical Breast Exam: At least every 3 years ages 20-39. Every year beginning at age 40.
-Breast Self Exam: Not recommended as screening tool. However rec: patients become familiar with their breastsInfertility•Subfertility: prolonged time to conceive
•Sterility: inability to conceive
•substance abuse
•Less than 35 yrs trying for over a year
•over 35 trying for 6 monthsFemale infertility•Ovarian factors
• Tubal and peritoneal factors
• Uterine factors
• Vaginal-cervical factors
-IsoimmunizationMale infertility•Can be caused by structural and hormonal disorders
•Undescended testes
•Hypospadias
•Varicocele (varicose vein of the scrotum)
•Low testosterone levels
*tests sperm count and quality of the spermMedical implementation for infertility•Assisted reproductive therapies
•IUI versus IVF- Clomid (associated with hyper ovulation, increased chance of twins), Injectables (encourage hormones)
•IUI: sperm placed into the uterus to increase sperm getting into fallopian tube, this is thought to be easier
•IVF: removes eggs and then fertilizes them outside the body; this may be done if sperm is less mobileIVF sample cycle of hormones involved-Lupron: keeps ovaries from creating follicle
-HMG: stimulate the follicle
-HCG:makes her ovulate
-Progesterone: prepares the uterine lining for an embryoContraception Nursing Care Management❖A multidisciplinary approach to assist the woman in choosing an appropriate contraceptive method
❖Ideally the method should be safe, readily available, economical, acceptable, and simple to use
❖The safety of a method depends on a woman's medical historyFertility awareness methods (FAM)•Rely on avoidance of intercourse during fertile periods
•FAMs combine charting menstrual cycle with abstinence or other contraceptive methods
FAM methods:
•Natural family planning (period abstinence)
•Calendar rhythm method
•Standard days method
Basal body temperature method
•Cervical mucus ovulation-detection method
•Symptothermal method
•Predictor test for ovulation
•TwoDay method: bc sperm is still alive
•Lactation amenorrhea method: BF without a period, but need to be BF Q2-3hrs bc hormone suppressionBarrier methods•Spermicides: can't be put in more than 1hr before sex
•Condoms, male (STI protection)
•Vaginal sheath (STI protection)
•Diaphragm
•Cervical cap
•Contraceptive spongeCombined estrogen-progestin contraceptives (COCs)•Contraindications: hx of blood clotting disorders
•Side Effects: HA, breast tenderness
•Decreased effectiveness by other meds: abx
•Fertility return
•EDUCATION for missed pills**
•Transdermal contraceptive system
•Vaginal ringProgestin-only contraceptives•Oral progestins (minipill): taken in you're BF bc estrogen prevents milk production
•Injectable progestins: depo prevera: shot Q12wks, RF wt gaint, spotting and irregular period
•Implantable progestins (Norplant): can last up to 5yrsEmergency contraceptionUsed within 72 hours of unprotected intercourse
•Three methods available in the United States
•High doses of estrogen or OCAs
•Two days of levonorgestrel
•Insertion of the copper intrauterine device (IUD)IUD•Small, T-shaped device inserted into the uterine cavity
•Medicated IUDs loaded with either copper (no hormone) or progestational agent
•IUD offers no protection against STIs or HIVSterilizationFemale
•Tubal occlusion
•Tubal reconstruction
•EDUCATION: not reversible
Male
•Vasectomy
•Tubal reconstruction (reanastomosis)Abortion law-bans abortion at around six weeks of pregnancy
-allows people across the country to sue anyone who helps someone get an abortion after six weeks in Texas
-$10,000 minimum reward for every successful lawsuit
-The legislation makes an exception in the case of medical emergency, which requires written proof from a doctor, but not for pregnancies resulting from rape or incestAbortion-Purposeful Interruption of pregnancy before 20 weeks of gestation
•Elective: mom chooses not to have a baby
•Therapeutic: baby not viable with life or mom at riskTypes of abortionFirst-trimester abortion
•Surgical (aspiration) abortion, Dilation & Curettage
•Methotrexate (IM or po) and misoprostol (PV)
•Mifepristone and misoprostol
Second-trimester abortion •Dilation and evacuation
•Hypertonic and uterotonic (MISOPROSTOL) agentsSTI prevention•Primary prevention: the most effective way of reducing STIs (sexually transmitted infections) in childbearing people.
•Secondary prevention: Prompt diagnosis and treatment can prevent personal complications and transmission to others.STI 5 P's-# of partners
-Protection against pregnancy
-Protection against STI's
-Pass history of STI's
-Practices of different sexual practicesSTI risk reduction measures-Assessment of risk-5 P's!
-Knowledge of partner
-Reduction of the number of partners
-Low-risk sex
-Avoiding exchange of body fluids
-Vaccination (HPV & Hep B)
-Education and counselingSTI risk reduction barriersPhysical barriers
•Condoms correctly applied with every sexual encounter.
-Male: Latex or plastic (not natural skin bc HIV can still penetrate through condom)
-Female (polyurethane sheath)
Chemical barriers
•Spermicides are not protective against STI's.
•Nonoxynol-9- may increase risk of HIV transmission.
Communication
•Expressing feelings and fears
•Attention to partner's response
•Nurses must suggest strategies to enhance a woman's condom negotiation and communication skills.
Vaccine
•Guardacil and Cervarex (HPV)
•Hep BChlamydia Trachomatis (info, transmission)Most common reportable STI
•Bacterial infection
•Infections often silent and highly destructive: women get tested at their 1st appointment
•Difficult to diagnose
•Sexually active women ages 15 to 24 years have the highest rates of infection, with women ages 18 to 20 years having the highest rates (CDC).
•Symptoms may include spotting, postcoital bleeding, purulent cervical discharge, dysuria.
Transmission:
-Genital to genital
-Oral-genital
-Anal genital
-Vagina-rectum
-Perinatal transmission
•Antibiotic ointment for conjunctivitis.
•Antibiotics for pneumoniaChlamydia Trachomatis (dx, management)Screening and diagnosis
•Asymptomatic women with risk factors
•and pregnant women in first trimester and at 36 weeks.
•Diagnosis by culture, DNA probe, enzyme immunoassay, nucleic acid amplification of urine specimens.
Management
•Doxycycline: can't be given during pregnancy
•Azithromycin (One dose: Preferred): can be given when pregnant
•All exposed sexual partners should be treated: tracing is doneGonorrhea-Aerobic gram-negative diplococcus (Neisseria Gonorrhoeae).
-Oldest communicable disease in the United States
-Second most common reportable STI
-Incidence of drug resistant gonorrhea is increasing
-Highest rates among teenagers, young adults
-Women often asymptomatic
-Perinatal complications:
•First trimester Salpingitis
•Premature rupture of membranes
•Preterm birth
•Chorioamnionitis
•Maternal and Neonatal sepsisGonorrhea (dx, management)Screening and diagnosis
•CDC recommends screening all women at risk.
•May be asymptomatic
•May have purulent endocervical discharge, menstrual irregularities, abdominal pain, back pain.
•Testing performed during first trimester and at 36 weeks of pregnancy
•Thayer Martin culture is used (endocervix, rectum, throat)
•Is a reportable disease
Management
•Antibiotic therapy: Ceftriaxone IM one dose.
-Drug resistance is increasing.
•Concomitant treatment for chlamydia
•Perinatal complications of gonococcal infection: preterm labor, premature rupture of membrane
•Partners must be treated
•Test for HIV co-infectionSyphilisTreponema pallidum, a motile spirochete:
•Earliest described STI
•Rates of transmission are increasing
•Transmission by entry into subcutaneous tissue through microscopic abrasions that can occur during sexual intercourse
•Also transmitted through kissing, biting, or oral-genital sex
Transplacental transmission may occur at any time during pregnancy:
•Syphilis is devastating if acquired any time in pregnancy
•malformation and neurological for the babySyphilis (complications)-Can lead to serious systemic disease and even death when untreated
-Infection manifests in distinct stages:
•Primary: Painless chancre: 5 to 90 days after exposure; when the bacteria enters the body, round painless chancre, fills with puss and then it bursts craters and covered over
•Secondary: Maculopapular rash on palms and soles of feet; Condylomata lata; with systemic symptoms: 6 weeks to 6 months, rash can be very painful
-LATENT PHASE: Asymptomatic
•Tertiary: neurological, cardiovascular, multiorgan devastation
-develops in one third of women infectedSyphilis (dx, management)Screening and diagnosis
•Sexually active individuals with any risk factors.
•Pregnant people at first prenatal visit and in third trimester.
•Serologic tests
-RPR & VDRL (nontreponemal): nontraditional, tests for antibodies
-FTA-ABS & TP-PA (treponemal): looks for actual bacteria in the blood
•False-positive results
•false-negative: if test done too early
Management
•ONLY Penicillin G
-Dose varies by stage.
•May cause Jarisch Herxheimer reaction
•Sexual abstinence during treatment
•Partners should be notified and treated.Pelvic inflammatory disease (PID)-An infectious process that most commonly involves the fallopian tubes, uterus, and occasionally the ovaries and peritoneal surfaces
-Multiple organisms have been found to cause PID. (most common: gonorrhea and Chlamydia)Pelvic inflammatory disease (PID) (RF and at Risk for...)-Risk factors for acquiring PID
•Young age
•Nulliparity
•Multiple partners
•High rate of new partners
•History of STIs and PID
•UID insertion within 3 weeks
-Those with PID are at increased risk for
•Ectopic pregnancy: eggs implant in the fallopian tubes
•Infertility
•Chronic pelvic pain
•Recurrence of PIDPelvic inflammatory disease (PID) (s/sx, dx, treat)Symptoms:
•Depend on type of infection
-Acute: severe, consistant abd pain
-Subacute: dull cramping
-Chronic: cramping pain, fever, discharge, irregular bleeding
Screening and diagnosis:
•History
•CDC routine criteria: lower abdominal tenderness, bilateral adnexal tenderness (ovarian tubers), cervical motion tenderness (pt has large reaction when assessed)
•May also have: Increased temp, abnormal discharge, elevated sed rate, CRP, documented chlamydia or gonorrhea
Management:
•Prevention: condoms, edu
•In or outpatient treatment, antibiotics (IV), pain control, good nutrition, rest, semi Fowler's position.
•Education: Contraceptive, barrier methods, risk factors
•Follow up for a test of cure after treatment.Human papillomavirus (HPV)-Condylomata acuminata
-Affects 20 million Americans
-Most prevalent viral STI seen in ambulatory health care settings
-Previously named genital or venereal warts
-More frequent in pregnant women
-100 types of HPV; only 2 are oncogenic (types 16 and 18)
-Pap smear may show HPV but pt may be asymptomatic, not to worry about bc usually gone by next testHPV (dx and management)Screening and diagnosis:
•Most cases are asymptomatic and resolve without treatment
•History of known exposure
•Physical inspection
•Pap test
•Viral screening and typing for HPV are available but not standard practice.
Management:
•Removal (cryotherapy)
•Medications (podopholin if not pregnant)
•Oatmeal baths, loose cotton clothing, good nutrition and stress reduction.
•Counseling (reinfection is always a possibility).
Prevention with Gardasil or Cervarix vaccination, females and males.Herpes simplex virus (HSV)-Herpes simplex virus 1 (HSV-1): Transmitted non sexually (cold sore)
-Herpes simplex virus 2 (HSV-2): transmitted sexually (asyclavir may help decrease the viral load)
-Initial infection characterized by multiple painful lesions, fever, chills, malaise, and severe dysuria, vulvar edema, cervicitis. 2-3 weeks
-Subsequent outbreaks usually less severe. 5-7 daysHerpes simplex virus (HSV) (management)-Chronic and recurring disease for which there is no known cure
-no sex (until sores are closed over), sharing towels, don't wash towels at the same time during an outbreak
-Systemic antiviral medications partially control the symptoms
•Acyclovir, valacyclovir, famciclovir
•Comfort measures
●Maternal infection with HSV-2 can have adverse effects on mother and fetus
●Neonatal herpes
-Most severe complication of HSV
-Most mothers lack history of HSVHepatitis A virus (HAV)-NOT SEXUALLY TRANSMITTED
•Acquired primarily through a fecal-oral route
•Vaccination the most effective means of preventing HAV transmission
•Characterized by flulike symptoms with malaise, fatigue, anorexia, nausea, pruritus, fever, and right upper quadrant painHepatitis B virus (HBV)•Most threatening to the fetus and neonate
•Disease of the liver and often a silent infection
•Transmitted parenterally, perinatally, and, rarely, orally as well as through intimate contact
•Vaccination series available
•No specific treatment; recovery is usually spontaneous within 3-16 weeks
•mom tested during first visit
•mom (+): neonate given Hep B and immunoglobins
•If they're pregnant when they are exposed should get the series and the immunoglobin-Hepatitis C virus (HCV)•Most common blood-borne infection in the United States
•Important health problem as increasing numbers acquire disease
•Risk factor for pregnant women is history of injecting IV drugs
•Interferon-alfa or ribavirin is main therapy for HCV infection
•Effectiveness of treatment varies
•moms can pass to babies during birthHuman immunodeficiency virus (HIV)-Heterosexual transmission now the most common means of transmission in women
-20% of these new infections occur in women
-Transmission of HIV occurs primarily through exchange of body fluids
-Severe depression of the cellular immune system associated with HIV infection characterizes AIDS
-Symptoms: fever, headache, night sweats, malaise, generalized lymphadenopathy, myalgias, nausea, diarrhea, weight loss, sore throat, and rash
-Readily transmitted to the fetus through maternal circulation early in pregnancy, or by exposure to blood and body fluids, or through breast milk.HIV (dx and counseling for testing)Screening and diagnosis
•Antibody testing
-Enzyme immunoassay with follow up Western Blot to confirm
•Detection
Counseling for HIV testing:
•Counseling before and after HIV testing is standard nursing practice today
•HIV testing offered early in pregnancy
•Perinatal transmission decreases
•Consider confidentiality and documentation
•Pretest and posttest counseling
•Notification of resultsHIV (management)•Resources
-Client needs will vary based on their circumstances
-Death and dying
-Suicide prevention
-Financial assistance
-Legal advocacy
•Prevention of transmission
•No cure available yetHIV and pregnancy•HIV counseling and testing should be offered to all women at their initial entry into prenatal care as part of routine prenatal testing unless the woman opts out of the screening (CDC, 2010c).
•Perinatal transmission has decreased because of antiretroviral prophylaxis.
-Decreases transmission to 1% to 2%
•Intrapartum zidovudine: given during labor and delivery
•Avoid invasive procedures such as use of FSE, AROM, scalp sampling.
•Cesarean birth is recommended: but if have a low viral load, vaginal is possible
•In the US, HIV positive women should be counselled not to breastfeed
•minimize invasive procedures to decrease RF transmissionVaginal Infections•NOT Sexually transmitted
•Vulvovaginitis: Inflammation of the vulva and vagina, Many different causes
Bacterial vaginosis (BV):
•Syndrome in which normal H2O2-producing lactobacilli are replaced with high concentrations of anaerobic bacteria
•Vaginal discharge has a "fishy" odor; discharge may be profuse, thin, white or gray.
•Some women complain of pruritic.
•Associated with preterm labor and birth
•Treatment with metronidazole orallyCandidiasis-Candida albicans or non-C. albicans infection
-Vulvovaginal candidiasis, or yeast infection, is second most common type of vaginal infection
-Numerous factors have been identified as predisposing a woman to yeast infections.
-In women with HIV, symptoms are more severe and persistent: itchy, redness, thick and sticky dischargeCandidiasis (predisposing factors)•Antibiotic therapy
•Diabetes
•Pregnancy
•Obesity
•Diets high in refined sugars
•Use of corticosteroids and hormones
•Immunosuppressed statesCandidiasis (s/sx, dx, treat)Common symptoms:
•Vulvar pruritus
•Vaginal pruritus
•Thick, white, lumpy vaginal discharge
Screening and diagnosis:
•Physical examination
•Vaginal pH
Management:
•Over-the-counter agents (-azole)
-Intravaginal treatment or oral agent
-Full course of treatment must be completed
-Other comfort measures
-no sexTrichomoniasis-Often considered an STI
-Common cause of vaginal infection
-Inflammation of the vagina and/or vulva
•Greenish, frothy mucopurulent discharge
•Cervix & vaginal walls may have "strawberry spots"Trichomoniasis (dx and treat)Screening and diagnosis:
•Speculum examination
•Pap test
Management:
•Metronidazole
•The risk for sexual transmission must be communicated to infected women.Group B streptococci (GBS)-A part of the normal vaginal flora, present in 20% to 30% of healthy women
-Associated with poor pregnancy outcomes
-Important factor in neonatal morbidity and mortality
-Screening at 36-37 weeks of gestation
-Intrapartum intravenous prophylaxis
-Can cause sepsis in baby
-treat: ampacillin and penicillin IVMaternal Effects of Infections In the Lower Genital tract•Infections in pregnancy are responsible for significant morbidity and mortality
Pregnancy effects:
•Premature rupture of membranes
•Premature labor
•Postpartum sepsis
•Dystocia
•MiscarriageFetal Effects of Infections of the Lower genital tract•Infections in pregnancy are responsible for significant morbidity and mortality.
Fetal effects:
•Preterm birth
•Pneumonia
•Systemic infection
•Congenital infection
•StillbirthTORCH infections-Form group of infections capable of crossing the placenta and adversely affecting the fetus. These are not necessarily sexually transmitted.
•Toxoplasmosis: from cat litter and raw meats
•Other infections (e.g., hepatitis, HIV)
•Rubella virus
•Cytomegalovirus
•Herpes simplex virus (HSV)Maternal and Fetal Effects of genital tract Infections: Care Management•Expected outcomes of care
-Focus on physical and psychologic needs with emphasis on avoidance of reinfection and harmful sequelae
-Infection control
•Plan of care and interventions
-Management during pregnancyInfection Control•Interrupting the transmission of infection is crucial to STI control
•Many STIs are reportable; all states require that these STIs be reported to public health officials
-Gonorrhea
-Syphilis
-Chancroid
-Lymphogranuloma venereum
-Granuloma inguinaleSTI keypoints•Prevention of mother-to-newborn HIV transmission is most effective when the woman receives antiretroviral drugs during pregnancy and labor and birth, and the infant receives the drugs after birth.
•HPV is the most common viral STI.
•Syphilis has reemerged as a common STI, affecting African-American women more than any other ethnic or racial group
•Chlamydia is the most common STI in women in the United States and the most common cause of PID.What is Genetics?-Genetics: Study of individual genes and their effects on relatively rare, single-gene disorders
-Genomics: Study of all the genes in the human genome together, including their interactions with each other, the environment, and the influence of other psychosocial factors and cultural factors
-Allows us to predict susceptibility, onset, progression, and response to treatment for many hereditary diseases
•Genetics:(just genes)
•Genomics: (genes +other factors)Human Genome Project-Publicly funded international effort by the National Institute of Health (NIH) and US. Department of Energy in 1990.
-Completed in 2003
-Mapped the human genome (the complete set of genetic instructions in the nucleus of each human cell)
•Two key findings:
-All human beings are 99.9% identical at the DNA level
-There are approximately 20,500 genes in the human genome
-More recently (2012), researchers have linked more than 80% of the genome to specific biological functions and figured out where proteins interact with DNAGene therapy (gene transfer)•corrects defective genes that are responsible for disease development.
•Involves inserting a healthy copy of the defective gene into the somatic cells of the affected individual.
•Diseases that could be treated with this range from hemophilia and other single-gene disorders to complex disorders such as cancerPharmacogenomicsFormulating medications specifically targeted to the genetic makeup of the patientWhat are the reasons patients decide either to be tested or not tested?-Seldom autonomous
-Based on feelings of and commitment to others
-Socioeconomic factors
-Cultural and ethnic differences
-Gap in ability to diagnose and ability to
treat•Ethical, legal, and social implications (ELSIs): genetics•How do I protect my genetic information in regards to privacy and discrimination?
-Privacy and fairness in use and interpretation of genetic information
-Clinical integration of new genetics technologies
-Issues such as possible discrimination and stigmatization
-Genetic Information Nondiscrimination Act of 2008(GINA)Essential Nursing Competencies and Curricula Guidelines for Genetics and Genomics•Constructs pedigree from collected family history information
•Develops plan of care that incorporates genetics assessment
•Provides patients with genetic information, resources, and services
•Facilitates referrals for specialized services
•Evaluates the impact and effectiveness of genetic and genomic technology, interventions, and treatments
•Ethical awareness is keyObstetric Nursing's Role in Genetics and Genomics•Preconception counseling and testing
•Neonatal genetic screening and testing
•Palliative care for infants with life-threatening conditions/conditions not compatible with life
•The identification and care of individuals with genetic conditions
•Specialized care of women with genetic conditions during pregnancy (unique as historically these women didn't always live to reproductive age)
-Congenital heart disease
-Cystic fibrosis
-Factor V LeidenGenetic Counseling in Pregnancy•Standard practice in obstetrics
•Goal is to identify risk
•Genetic history should be obtained using a questionnaire or checklist
•Genetic counseling
-Information
-Education
-SupportGenetic Counseling estimated risks•Occurrence risk: Parents are known to be at risk for producing a child with disease; what's the risk of their child having the disease?
•Recurrence risk: Once they have produced a child with disease, what's the chance their next child will also have the disease?
•Interpretation of risks: very personal decision-making process for parentsWhat are the reasons to get different types of genetic testing-Carrier screening tests
-Predictive testing: used to clarify the genetic status of asymptomatic family members. Two types are:
1. Presymptomatic testing: if the gene mutation is present, symptoms of the disease are certain to appear if the individual lives long enough. (i.e Huntington's Disease)
2. Predispositional testing: BRCA 1 gene, a positive does not indicate a 100% risk for developing the condition (breast cancer)
-Population-based screening: Newborn screening for phenylketonuria (PKU) and over 30 other inborn errors of metabolismPrenatal tests-used to identify the genetic status of a fetus at risk for a genetic condition (done in 1st trimester)
•Maternal serum screening: a blood test used to see if a pregnant woman is at increased risk for carrying a fetus with a neural tube defect (NTD) or chromosomal abnormalities (Down syndrome, Trisomy 18 or Trisomy 13)
Genetic Testing in Obstetrics: screeningFetal ultrasound-Imaging of the fetus inside the uterus obtained by using high-frequency sound waves. Can screen for physical features associated with genetic abnormalities
Genetic Testing in Obstetrics: screeningAmniocentesis-Invasive procedure that obtains fetal DNA from amniotic fluid; after 15 weeks gestation
Genetic Testing in Obstetrics: dxChorionic villus sampling-invasive procedure obtaining fetal DNA from chorionic villi; before 15 weeks gestation
Genetic Testing in Obstetrics: dxClinical Genetics: Words You Need to Know!•DNA
•Chromosomes (46, 23 from each parent)
•Genes
•Homologous (matched pairs of chromosomes)
•Autosomes (22 pairs)
•Sex chromosomes (1 pair)
•Loci (gene location on the chromosome)
•Alleles (genes that code for variations of the same trait...hair color, eye color, etc.)
•Homozygous
•Heterozygous
•Genotype
•Phenotype
•Dominant
•Recessive
•Karyotype: A pictorial analysis of the number and size of an individual's chromosomes
•Pedigree Chart: family chart to show inheritance patternsWhat are Chromosomal Abnormalities?•A major cause of reproductive loss, congenital problems, and gynecologic disorders
•Can occur during mitosis (somatic cell-autosomal disorders) or meiosis (sex cells-sex-linked disorders)Autosomal abnormalities•Abnormalities of chromosome number (too many or not enough)
-Down's syndrome
Abnormalities of chromosome structure:
•Translocation
-Reciprocal translocation
-Balanced translocation
-Robertsonian translocation
•Duplication
•Deletion
•InversionTrisomy 18•AKA Edwards' Syndrome
•Severe to profound intellectual disability
•Most don't survive to their 1st birthdayTurner syndrome: sex chromosome abnormalities•Monosomy x (1 X)
•Most common deviation in females
•Short in stature and webbing of neck, low hairline; intelligence may be impairedKlinefelter syndrome: sex chromosome abnormalities•Trisomy xxy
•Most common deviation in males
•Affected males have poorly developed secondary sexual characteristics and small testes. Usually infertile, usually tall and may be slow to learnPatterns of Genetic Transmission-Unifactorial•A single gene controlling a trait, disorder, or defect
-EX: autosomal dominant or recessive inheritanceAutosomal dominant inheritance•An affected parent who is heterozygous for the trait has a 50% chance of passing the variant allele to each offspring. No skipping of generations.
•Males and females are equally affected
•Example: Huntington's Disease, Marfan SyndromeAutosomal recessive inheritance•Both genes of a pair associated with the disorder must be abnormal for the disorder to be expressed.
•The chance of the trait occurring in each child is 25%
•Examples: Cystic fibrosis, sickle cellPatterns of Genetic Transmission-Inborn Errors of Metabolism-More than 350 inborn errors of metabolism have been recognized
-Most are inherited in an autosomal recessive pattern
-Occur when a gene mutation reduces the efficiency of encoded enzymes to a level at which normal metabolism cannot occur.
-Defective enzyme action interrupts the normal series of chemical reactions from the affected point onward (PKU)Patterns of Genetic Transmission-X-Linked Dominant-Occurs in males and heterozygous females, but because of X inactivation, affected females are usually less severely affected than affected males
-The affected males transmit the variant allele to their female offspring (no male-to-male transmission)
-Heterozygous females have a 50% chance of transmitting the variant allele to each offspring.
•Example: Fragile X syndrome, Rett syndromePatterns of Genetic Transmission:X-Linked Recessive•Abnormal genes carried on the X chromosome.
•Females may be heterozygous or homozygous for traits carried on the X chromosome
•Males are hemizygous because thy have only one X chromosome
•Most commonly manifested in the male with the abnormal gene on his single X chromosome
•Female carriers (heterozygous for the trait) have a 50% probability of transmitting the disease-associated allele to each offspring.
•An affected male can pass the disease-associated allele to his daughters but not to his sons
•Examples: hemophilia, color blindness, and Duchene muscular dystrophyPatterns of Genetic Transmission: Multifactorial•Most common genetic malfunction
•Combination of environmental and genetic factors
ex:
•Cleft lip and palate
•Congenital heart disease
•Neural tube defects
•Pyloric stenosisZygoteFirst 2 weeks after conceptionEmbryoBetween 2 and 8 weeks after conception
*at greatest risk of insult from teratogenFetusFrom 8 weeks until birthZygote releases ___ once it implantsreleases HCG to keep corpus luteum intact until the placenta takes overMeiosiscells start as diploid (46 total, 44 autosomal, 2 sex) and become haploid (23 total, 22 autosomal, 1 sex)Sperm•Produced by meiosis
•Capacitation
•Acrosomeovulation occursday 14, 2 weeks after the 1st day of her period
•Pregnancy lasts 280 days - calculated from first day of last menstrual period (LMP)Fertilization•takes place in the outer third of the fallopian tube
•Zygote: first cell of the new individual
•Morula: 16 cells
•Blastocyst: trophoblast (outer layer that sit on uterine lining), embryoblastConception to Implantation2 weeksImplantation•6-10 days after conception
•Chorionic villi
•Decidua basalis, decidua capsularis, decidua vera
Teratogen Exposure Now = All or NothingPrimary germ layers•Ectoderm
•Mesoderm
•EndodermDevelopment of the Embryo•lasts from day 15 until 8 weeks after conception
•Most critical time for developmentDevelopment of the embryo•Membranes
-Amnion: filled with fluid, closer to baby
-Chorion: from trophoblast; outer layer with umbilical blood vessels, closer to mom
•Amnionic cavity
•Amniotic fluid: protect baby, helps with thermoregulation, helps the lungs develop and stretch; fluid comes from maternal fluid and plasma and then later babies produce it
•Placenta
•Umbilical cord: brings O2 and nutrients to the baby and gets waste out
-Wharton's jelly: if absent RF hemorrhage
-Three vessels: 2 arteries (away-blue) and 1 vein (O2 and blood to the baby, red)Functions of the Placenta•Metabolic: Respiration, Nutrition, Excretion, Storage
•Endocrine: Human chorionic gonadatropin (first 130 days), Human placental lactogen, Progesterone, Estrogen
Immune:
•IgM: Made by placenta
•IgA: Present in breastmilk
•IgG: Crosses placenta from Mom
*Rh given to - mom and +babyEmbryonic and Fetal Development•Stage of the fetus lasts from 9 weeks until the pregnancy ends
•Fetal maturation: Viability
•Fetal circulatory system
-Ductus arteriosus
-Ductus venosus
-Foramen ovaleCardiovascular System (embryo and fetus)•Heartbeat by end of week 3
•Gas exchange in placenta, not lungs.
•Umbilical cord has 2 arteries & 1 vein.
•Fetal compartment is relatively hypoxic.
•Fetal hemoglobin is different
-50% greater Hg concentration
-Fetal HR is 110-160 bpmHematopoietic system (embryo and fetus)•Blood cells form in the yolk sac until week 6 (yolk become digestive system)
-Fetal liver until weeks 8-11
-Stem cells in bone marrow, spleen, thymus by week 8
•Fetal Hemoglobin: compensitory mechanism bc it's hypotic enviornment
•Rh Factors
-Antigenic factors present by week 6: but determined at conception
-Rhogam: mom is negative and baby is positive
*baby is acidotic while mom is alkalosis which allows for exchange to occurGastrointestinal system (embryo and fetus)•Foregut, midgut, hindgut form in week 4.
-5-10 weeks: risk for fetal malformations of the gut.
•Fetus is swallowing at 24 weeks with peristalsis occurring (meconium).
•Fetal gut mature by 36 weeks EXCEPT bacterial colonization: BF optimal colonizationHepatic system (embryo and fetus)•Liver develops from foregut in week 4.
•Glycogen storage in liver by 9 weeks gestation.
•Liver stores iron-enough for 5 months after birth: then supplement needed
•Fetal liver does not conjugate bilirubin in fetal life-risk for jaundice.
•Coagulation factors II, VII, IX and X not synthesized in fetal gut-no vitamin K: RF hemorrhage
•Neonatal liver is relatively immature.Respiratory system (embryo and fetus)•Development starts at week 4
•Respiratory movements visible by 11 weeks.
-Last system to develop fully
•Pulmonary surfactants: develops in fetal lung, decrease surfance tension to prevent lung collapse. at birth the lungs are able to expand and clear fluid
-By 32 weeks
•Lecithin/Sphingomyelin ratio: looks at amniotic fluid. test done to assess amount of surfactant present and if extrauterine life is possible
-2:1
-glucocorticoids can help the baby's lung mature if born too earlyRenal system (embryo and fetus)•Kidneys formed by 4 weeks & functioning by 9 weeks.
•Oligohydramnios: low amniotic fluid, RF kidney issues bc not peeing
•Polyhydramnios: too much amniotic fluid, RF esophageal issues bc baby isn't swallowing
•At birth neonatal kidneys do not concentrate urine well: lots of urine output
•should have 1st void within 24hrs of birth
•baby needs 1 void and 1 BM before dischargeMusculoskeletal system (embryo and fetus)•Musculoskeletal system
•Bones and muscles by week 4
•Muscle contraction by week 11
-Thumb sucking, kicking, turning.
•Fontanels: Bones not fused
•Quickening: 16-20 weeks
-Fetal movement is key indicator of baby's well beingIntegumentary System (embryo and fetus)•Vernix: protects skin from amniotic fluid
-Thick by 24 weeks and thins by term..
•Lanugo: body hair
-Entire body by 20 weeks & regresses as they get closer to termImmunologic System (embryo and fetus)•IgG: Crosses the placenta!
•IgM: Produced by fetus 1st Trimester
•IgA: BreastmilkNeurologic system (embryo and fetus)•Sensory awareness
•Purposeful movements
•Pain sensation
•Respond to sound by 24 weeks
•Distinguish taste by 20 weeks
•Vision by 26-28 weeksEndocrine system (embryo and fetus)•Insulin does not cross the placenta. Glucose does.
-mom and baby produce their own insulinReproductive system (embryo and fetus)sex of baby determined at conception and structure not formed until months laterTwins•Dizygotic: 2 eggs (preterm is usual bc placenta runs out of room)
•Monozygotic: 1 egg split
-mono-mono: same placenta and sack, highest rf complications
-Di-Di: own placenta and sac
-Mono-di: 1 placenta, 2 sacs
•Conjoined: 1 eggPregnancy Tests•Human chorionic gonadotropin (HCG or Beta subunit): Earliest biological marker for pregnancy, made by trophoblast cells.
•Detected in maternal serum or urine 7-8 days before expected menses.
•Levels can screen for well being
•Home pregnancy test use depends upon literacy level and ability.
•False Positive = anticonvulsants & tranquilizers
•False Negative = Diuretics & PromethazineMaternal Adaptation: psychological response to pregnancy•Accepting the pregnancy
•Identifying with the mother role
•Reordering personal relationships
•Establishing a relationship with the fetus.
•Preparing for the birthEstablishing a Relationship with the FetusPhase 1:
•Acceptance of pregnancy
•"I am pregnant".
Phase 2:
•"I am going to have a baby"
Phase 3:
•"I am going to be a mother"Partner Reactions to Pregnancy•Accepting the pregnancy:
-Announcement phase: shocked, ambivalent
-Moratorium phase: helping partner adjust
-Focusing phase: reading to baby, talking to baby
•Identifying with the parent role
•Reordering personal relationships
•Establishing a relationship with the fetus
•Preparing for the birthAdaptation for LGBTQIA Couples•Families can be organized in many different configurations.
•Research is limited
•Listening and respecting their wishes is key.
•Equitable care means everyone gets the resources they need to thrive.Sibling and grandparent Adaptation: psychological response to pregnancySibling Adaptation:
•Loss or jealousy
•Varies by sibling age
•parents should prep their kids
Grandparent Adaptation:
•"Claiming"
•Historian
•Support system
•Ambivalence
•Can be negative influence: telling Horror stories!Prenatal Care Management•Can be provided by physicians, nurse midwives or professional midwives.
•Optimal care is team based care: provider, nurses, specialists, childbirth educators,
•Culturally sensitive care: Establish trust and listen.
•Emphasis on preventive care and optimal self-careVocabulary to Describe Gestational Age of Fetus•Preterm: 20-37 weeks
•Late Preterm: 34/0 and 36/6 weeks
•Early Term: 37/0 and 38/6: at RF resp issues
•Full Term: 39/0 and 40/6.
•Late Term: 41/0 and 41/6.
•Postterm: 42/0: RF placenta decline
•Viability: ? Between 22-25 weeks.Vocabulary to Describe Pregnancy (Gs and Ps and all that)•Gravida: Pregnant woman
•Gravidity: Pregnancy, state of being pregnant
•Nulligravida: never been pregnant
•Primigravida: first time being pregnant
•Multigravida: multiple pregnancies
•Parity: Pregnancies reaching 20 weeks (single or twin, live or stillborn)
•Nullipara: never carried past 20 wks
•Primipara: first time carrying to 20wks or beyond
•Multipara: multiple pregnancies past 20 wksTwo Digit System•Gravida: how many pregnancies
•Para: pregnancy reaching 20 wkeFive Digit System•Gravida: # of pregnancies
•Term: delivered >37wks
•Preterm: deliver between 20-37 weeks
•Abortions: deliveries before 20 wks, spontaneous or induced
•Living ChildrenPrenatal Visit Schedule•First visit within the first trimester
-Establishes baseline
-Identifies problems early
-Risk assessment is continuous
•Monthly visits weeks 16 through 28
•Every two weeks from weeks 29 to 36
•Weekly visits week 30 to birth
•Pregnant people with risk factors may need more frequent visitsInitial Prenatal Visit•Prenatal Interview
•History of current pregnancy
-LMP: last menstrual period
-Response to pregnancy
-Discomforts
•Reproductive & Sexual History
•Health History
•Medications, Herbs,
Substances & ImmunizationsNägele's RuleLast Normal Menstrual Period
-Subtract 3 from the month
-add 7 days
-adjust the ear
*Gives you: Estimated Date of Delivery (EDD)Estimated Date of Confinement (EDC)Follow-Up Visits (pregnancy)•Interview
•Education and Counseling
•Physical examination & VS
-More focused
-Weight
-Edema
•Routine Labs
-Clean catch UA: Protein, glucose, nitrites, leukocytes.
•Fetal Assessment
-Fundal Height: fundal height should match gestation age (20cm = 20wks)
-Gestational age
-Fetal movement: 16-20wks
-Fetal heart tones: 110-160
-Ultrasound examination (first and second trimester)
-Genetic screeningAbdominal Assessment of a Pregnant Patient•Fetal well-being can be assessed by measuring fundal height.
•Between 18 and 30 weeks cms should match weeks.
•Watch maternal positioning: Supine Hypotension (p. 190).
•Verifies gestational age
-Fetal heart tones
-Quickening & Fetal MovementPelvic examination•External inspection and palpation
•vulvar self examination
•Collection of specimens
•Papanicolaou test
•Vaginal wall examination
•Bimanual palpation
•rectovaginal palpation
*start at 21, Q3yrs and after 30 Q5yrsPatient Education and Counseling (health promotion)•Education about maternal and fetal changes
•Education for self-management
•Nutrition
•Physical activity
•Posture and Body Mechanics
•Rest and relaxation
•Medications & Herbal preparations
•Substance use
•Immunizations
•Rh Immune Globulin
•Personal hygiene
•Prevention of urinary tract infections
•Kegel exercises
•Preparation for breastfeeding newborn
•Dental health
•Preparations for birth and breastfeedingNutrient Needs Before Conception•Healthful diet before conception
-Promoting health overall
•Folate or folic acid (Box 9.1)
-Deficiency related to neural tube defects
-Dose 0.4 mg every day for all women of childbearing age.
-Sources: Liver, Legumes (peas, beans, lentils), asparagus, spinach, fortified foodsKey Components of Nutrition Care-Nutrition assessment
-Diagnosis of nutritional or risk factors
-Intervention based on an individual's dietary goals
-Evaluation with referral to a nutritionist or dietitian as necessaryFactors that contribute to the increase in nutrient needs•Development and growth of utero-placental unit.
•Total blood volume (plasma and red cell volume) increases by 40-50% during pregnancy.
•Maternal mammary development.
•Twenty percent (20%) increase in metabolic rate during pregnancy.
•Dietary Reference Intakes (DRI's) provide a guideline for intake preconception, during pregnancy & lactationNutrient Needs During Pregnancy•Energy needs
-Weight gain during pregnancy:
-Dependent upon her pre-pregnancy BMI
-Dependent upon risk factors or health issues.
-Increased with multiple gestation
•Pattern of weight gain and the quality of the food consumed is important.Weight Gain During Pregnancy• Low pre-pregnancy weight or low weight gain
-Risk: Preterm birth and small for gestational age babies.
•Overweight or Obese Women
-Fetal Risk: Miscarriage, birth defects, stillbirth, abnormal fetal growth, preterm birth, birth trauma, hypoglycemia in neonate.
-Maternal: gestational diabetes, hypertension, operative birth, assisted vaginal birth, infection, venous thromboembolism, depressionNormal BMI (18.5-24.9) wt gainFirst Trimester: 2-4 lbs (0.9-1.8kg) total
Second & Third Trimester: 1 lb (0.45 kg) per week
Total Weight Gain : 25-35 IbLow BMI (<18.5) wt gainFirst Trimester: 2-4 lbs (0.9-1.8kg) total
Second & Third Trimester: 1 lb (0.45 kg) per week
Total Weight Gain: 28-40 IbHigh BMI
Overweight = 25-29.9
Obese = 30 or above wt gainFirst Trimester: 2-4 lbs (0.9-1.8kg) total
Second & Third Trimester: Overweight = 0.6 lb (0.3 kg)
Obese = 0.5 lb (0.2 kg)
Weekly gain
Total Weight Gain :
Overweight 15-25 lbs
Obese 11-20 lbsNutritional Requirements During Pregnancy: What Does that Really Mean?•Calories: Recommended 340 kcal over prepregnant intake in second trimester, 450 kcal over prepregnant intake in third trimester.
Carbohydrates:
•No specific recommendations.
Fats:
•No specific recommendations for fats, but oils are a better option generally.
•6 teaspoon (30 mL per day).Nutritional requirements during PregnancyProtein:
•70 Grams/day
•3-4 servings of dairy OR
•2 servings of meat
•Most Americans get enough (maybe too much).
•Fluid - 8-10 glasses/dayPrenatal Iron•Non pregnant: 18mg for 18 or older
•Pregnant: 30 mg/day for all
•Lactating: 10mg/day for 18 or older.Prenatal Ca•No increase in DRI from non pregnant, pregnant to lactating.
•1000 mg/day over 18.Prenatal electrolytes and minerals•Magnesium: 350 mg
•Choline: 450 mg/day (fetal neural development)
•Zinc: 8 mg/dayPrenatal Nutrition: Fluids and Electrolytes•Fluids: 8-12 cups/day
•Sodium:Slightly increased need during pregnancy; DRI <2300 mg/day
•Potassium: good diet will provide adequate intakePrenatal vitamins (fat soluble)oFat-soluble vitamins: Large body stores
oSupplement only by prescription
oA
oD
oE
oKPrenatal vitamins (water soluble)oWater-soluble vitamins: Fewer body stores, rapidly excreted
oDaily supplementation may be ok.
•Folate or folic acid
•Pyridoxine
•Vitamin C
•Vitamin B 6 & B12Caffeine and artificial sweetenersCaffeine:
•Unclear if there is a safe level.
•Recommend <200 mg/day (2 cups coffee)
Artificial Sweeteners
•Aspartame, acesulfame potassium (Sunnett) & sucralose (Splenda) are FDA approved.
•Aspartame contains phenylalanine
•Stevia and agave: Not enough data on these.Vegetarian & Vegan Diets•May mask an eating disorder
•Can vary widely in terms of intake
•If they are carefully balanced these diets can be adequate.
•Poorly planned can be deficient in iron, zinc, Vitamin D, E, B12, choline, calcium and fatty acids.
*if eat eggs and dairy may be getting adequate nutrientsGluten free diets•No established benefit unless diagnosed with celiac disease or other autoimmune disorder.
•May be deficient in folate, thiamin, niacin, riboflavin and iron.Adolescent Pregnancy Needs (nutrition)•Increased risk for complications during pregnancy, labor and birth.
•Competition for nutrients in two separate bodies: with different needs so dietician needed
•Likely to have insufficient diets- especially calcium and iron.
•Weight gain goals are not different, but ideal weight gain target may be at upper end of recommended range.
•Adolescents who have given birth have higher BMI generally.
•Eating high quality foods is a key goal
•Understanding factors that create barriers to care and to excellent nutrition.
•Nonjudgmental prenatal carePhysical activity during pregnancy•Adequate fluid intake is essential
-2-3 eight ounce glasses of water after each exercise session.
•Calorie intake sufficient to meet increased needs of pregnancy and exercise
-Healthy snacks
-Competitive athletes may need to see a nutritionist
•encourage low impact exercises: 30 minute walk or swim 30-40 minutesNutrient Needs During Lactation•Nutrition needs during lactation similar to those during pregnancy
•450-500 cal per day above non pregnant daily intakes
•Increased intake of zinc, Vitamin A, E, C, B6 and B12
•Increased maternal weight loss during lactation
•Smoking, alcohol intake, and excessive caffeine intake should be avoided during lactationIndicators of Nutritional Risk•Adolescence or <2 yrs after menarche
•Closely spaced pregnancies
•History of poor fetal outcomes
•Poverty/food insecurity
•Poor dietary habits & unwilling to change
•Use of tobacco, ETOH & drugs
•Preconception obesity or underweight
•Abnormal pregnancy weight gain pattern
•Weight loss
•Multifetal pregnancy
•Anemia
•Diabetes
•Chronic illnessPhysical Assessment of Nutritional Status•Signs of poor nutrition include:
•General listlessnes, apathy
•Flaccid, poor muscle tone
•GI disturbances (anorexia, diarrhea, constipation, etc).
•Tachycardia, enlarged heart, abnormal heart rhythm or BP
•Stringy, dull brittle hair
•Rough, dry, scaly, easily bruised skin.
•Thyroid enlargement
•Gums spongy with easy bleeding, inflamed or receding gums. Evidence of dental or tooth disease
•Eye membranes pale, redness & fissures at eye corners.
•Edema of extremities, tender calves, tingling, weakness; nails spoon shaped or brittle.
•Bow legs/knock knee/ chest deformity.Parity•number of pregnancies carried past 20 weeks - not number of fetuses born & regardless of alive or stillbornGravida•a woman who has been pregnantPrimigravida•a woman pregnant for the first timePrimiparaa woman who has delivered one child past gestation of 20 weeksMultigravida•a pregnant woman who has been pregnant beforeMultipara•a woman who has carried two or more pregnancies to 20 weeks or moreNulligravida•a woman who has never been and is not currently pregnantNullipara•a woman who has not completed a pregnancy with a fetus or fetuses who have reached 20 weeks or morePreterm-pregnancy that has reached 20 weeks of gestation but before completion of 37 weeks of gestation (20- 36.6 wks)Viability-capacity to live outside uterus; about 22 to 25 weeks gestation are on the threshold of viability
•These very premature infants are vulnerable to brain injuryEarly Term-37 0/7wk- 38 6/7wksFull Term39 0/7wks- 40 6/7wksLate Term41 0/7wks- 41 6/7wksPost Term-42 0/7wks and beyond Term: pregnancy from beginning of week 38 of gestation to end of week 42 of gestationTermfrom beginning of wk 38 gestation to end of 42 gestationPregnancy Tests: best test during first void bc more concentrated•Human chorionic gonadotropin (hCG) is earliest biochemical marker of pregnancy
-higher levels may indicate twins, wrong date, molar pregnancy, etc
•Pregnancy tests based on recognition of hCG or β subunit of hCG
•Can be detected in serum or urine as early as 7 to 8 days after ovulationEnzyme-linked immunosorbent assay-testing is most popular method of testing for pregnancy
•ELISA technology is the basis for most over-the-counter home pregnancy tests
•Medication use, hormone based tumors, or improper collection may cause inaccurate resultsPresumptive Signs of Pregnancy•Least indicative of pregnancy: what pt came in saying they have
•Amenorrhea
•N/V
•Breast changes
•Quickening: 'butterflies'
•Skin changes
-Linea nigra: line on abdomen
-Melasma: mask of pregnancy
-Striae gravidarum: stretch marksProbable Signs of Pregnancy•More reliable & more diagnostic, but not true diagnosis
•Positive lab tests
•Chadwick's sign
•Goodell's sign
•Hegar's sign
•Ballottement
•Fetal outline felt by examinerPositive Signs of Pregnancy•Ultrasound of fetus
•Fetal heart tones by Doppler or ultrasound: that are different from the mom's
•Fetal movement felt by examinerCervix•More vascular & edematous
•Goodell's sign -Softening of cervix- throughout pregnancy to prepare for delivery
•Chadwick sign- bluish hue of the cervix and vagina: bc increased blood flow
•Hegar Sign- Softening of the area between the cervix and body of the uterus
*probable signs of pregnancyOvaries•Ovulation stops
•Corpus luteum secretes progesterone & estrogen up to 16 weeks
-Maintains pregnancy until placenta formed & functioningVagina•Chadwick's sign
-Increased vascularity of vagina
-Vagina purplish (and cervix)
•Increased acidity to resist bacteria
•Increased sensitivity
•Leukorrhea- normal increased vaginal discharge (usually not an issue as long as there is no odor or pain)Breasts•Increase in size, vascularity
•Feelings of fullness & tenderness as early as 6 weeks
•Colostrum as early as 16 weeks
*** Education- Supportive bra; Discuss value of breastfeeding early; Reinforce self breast examResp system•Shortness of breath
-Diaphragm displaced upward, progeston may cause SOB
•Lungs expand horizontally
•Nasal congestion
-Elevated estrogen
-Capillary engorgement
** Education:
Warm compresses, humidifier, position changes (no psuedofeds)Cardio system•Blood volume increases 1500 ml
-1000 ml plasma
-450 ml RBCs
•Blood volume 25-40% greater than nonpregnant levels: may lead to discoer underlying heart conditions
•Physiologic anemia: apparent decrease in hemoglobin & hematocrit: bc of increased volume
•RBC production increases 30-33%Supine hypotension syndrome-Lying supine obstructs blood return from extremities, decreases cardiac output, hypotension; don't want them compressing vena cava
** Education- Tilt; change positions slowlyHemoglobin and WBC preg A&P•Hemoglobin- less than 11.5 g/Dl or hematocrit less than 30% is considered anemia
•WBCs -increase to 5000-12000/cubic mm.Cardiac output increases preg A&P•30 - 50%
•Increased Pulse (14-20-wk)
•Increased Cardiac output
•Decreased Blood Pressure (slight)- 1st trimester- 32wks Back to baseline in 3rd trimesterRenal System•Urinary output increases
-Urinary Frequency
•Specific gravity decreases
•Protenuria *** (not present in normal pregnancy except L&D or trace during delivery): if not in labor can be sign of preeclampsia
•Creatinine clearance best test of renal function
-Done on 24-hour urine sample: tests all voids expect the first one of the day
*** Education: Empty bladder completely (helps to lean forward); limit fluid intake in evening; avoid caffeineGastrointestinal System•Nausea/vomiting: Causes
-HCG & progesterone increase
-Estrogen increase
-Glucose levels decrease
-Test urine to ensure not dehydrated
-solved around 12wks
•Heartburn due to displacement of stomach by uterus - pyrosis
•Slowing of GI tract leads to constipation, flatulence, heartburn (progesterone slows system down)
•Decreased tone and motility GI- incr P4
•Reflux; Heartburn (pyrosis)
•Hemorrhoids common
•Pica - cravings for non-food items such as clay, laundry starch, and ice
•Gallstones
•Cholestasis
•Ptyalism - excessive
salivationGI education•Small frequent meals;
•Separate liquids from solids
•Ginger; B6
•Eat crackers before getting out of bed
•Avoid greasy, spicy foods or triggers
•Stool SoftenersMusculoskeletal System•Pelvic ligaments soften: in 3rd trimester
•Excessive mobility of joints: bc of instability
•Lordosis - pride of pregnancy, leaning back and sticking stomach out
•Diastasis recti: abdominal muscles splitting
*** Education-
•Maternity Belts
•Posture & mobility: don't bend over the waisteIntegumentary System•Chloasma - "mask of pregnancy"; darkening of skin on cheecks, usually gone after pregnancy caused by hormones
•Linea nigra - dark pigmentation down center of abdomen; caused by hormones. Use SPF when outside to prevent it from being permanent
•Striae gravidarum - stretch marks; usually doesn't go awayNeurological•Compression pelvic nerves
•Carpal Tunnel Syndrome- 3rd trimester; extra blood volume or swelling in the 3rd space of the hands
•Tension HeadachePsychological Changes•Maternal adaptation
•Emotional Lability
•Fatigue (hemodynamic & metoblic changes)
*** Education- discuss normalcy of emotional mood swings and mixed feeling early in the pregnancy;
* s/sx depression review;
* encourage naps;
* exercise and healthy dietNursing Management of Minor Discomforts of Pregnancy: N/V-High hCG and progesterone levels & changes in carbohydrate metabolism
-Avoid empty and overloaded stomach - eat more frequent smaller meals
-Dry toast 30 minutes before getting out of bed
-Hot drinks
-Get up slowly
-Avoid greasy foods
-Sweet lemonade may help
-Diclegis: Formerly Bendectin - off the market for 30 years, just returned to use in 2013 by FDA approval. It is composed of Vitamin B6 and an antihistamine-doxylamine.Nursing Management of Minor Discomforts of Pregnancy: heartburn-Pressure of fetus on stomach and decreased GI tract motility lead to reflux
-Low fat diet
-Pat off butter before meals to inhibit excretion of acid in stomach
-Eat several small meals rather than 3 large ones
-Aluminum or magnesium based antacids
-Sit upright after meals
-Avoid coffee & cigarettes (stimulate acid secretion)Nursing Management of Minor Discomforts of Pregnancy: Flatulence-Due to undesirable bacterial action
-Eat small amounts of well-chewed foods
-Avoid constipation
-Avoid gas forming foodsNursing Management of Minor Discomforts of Pregnancy: Frequent Urination-Early & Late pregnancy
-Encourage to drink fluids in morning & afternoons, decreasing fluids in eveningNursing Management of Minor Discomforts of Pregnancy: Backache-Teach good posture & body mechanics
-Teach to bend from knees rather than back
-Teach to wear shoes appropriate for activity
-Exercises to strengthen back musclesNursing Management of Minor Discomforts of Pregnancy: Dyspnea-Encourage mom to prop up with pillows when in bed
-Teach to sit & stand erect to lift diaphragm upNursing Management of Minor Discomforts of Pregnancy: Varicose Veins-Weight of fetus on saphenous veins of legs leads to increased pressure in veins
-Can occur in legs & vulva
-Prevention is easier than treatment
-Avoid restricting clothing, knee-highs
-Teach to elevate legs periodically
-Good fitting elastic stockings are usefulNursing Management of Minor Discomforts of Pregnancy: Leg Cramps-Pressure of enlarged uterus/fetus on nerves of lower extremities, fatigue, chilling
-Decreased serum calcium, increased serum phosphorus
-Decrease milk intake and supplement with calcium supplements (Milk increases phosphorus)
-Aluminum hydroxide gel removes some phosphorus
-Regular exercise
-Immediate relief: dorsiflex foot & put pressure on knee to straighten legSigns of Potential Complications: 1st trimester-Severe vomiting
-Chills, fever
-Burning on urination
-Diarrhea
-Abdominal cramping
- Vaginal bleedingSigns of Potential Complications: 2nd and 3rd-Persistent, severe vomiting
-Sudden discharge of fluid from vagina before 37 weeks
-Vaginal bleeding, severe abdominal pain
-Chills, fever, burring on urination, diarrhea
-Severe backache or flank pain
-Change in fetal movement
•Uterine contractions; pressure; cramping before 37 weeks
-Visual disturbances: blurring; double vision, spots
-Swelling of face or fingers and over sacrum
-Headaches; sever, frequent, or continuous
-Muscular irritability or convulsions
-Epigastric or abdominal pain (perceived as heartburn or severe stomachache)
-Glycosuria, positive glucose tolerance test reactions/sx to report to dr. in 2nd and 3rd trimester-Sudden discharge of fluid from vagina before 37 weeks
-Vaginal bleeding, severe abdominal pain
-Change in fetal movement
-Uterine contractions; pressure; cramping before 37 weeks
-Visual disturbances: blurring; double vision, spots
-Visual disturbances: blurring; double vision, spots
-RUQ pain
*may be signs of preeclampsiaAvoidance of Teratogens•Avoid cat litter boxes - toxoplasmosis
•Avoid exposure to infectious diseases
•Avoid all drugs not prescribed during pregnancy
•No alcohol
•Avoid cigarettes - causes growth retardationBiophysical RF◦Originates with the mother or the fetus
◦May affect development and functioning of both
◦Genetic disorders, nutritional and general health status, and medical or obstetric-related illnessesPsychosocial RF◦Maternal behaviors and adverse lifestyles that have a negative effect on health of mother or fetus: alcohol and smoking
◦May include emotional distress and disturbed interpersonal relationships
◦Inadequate social support
◦Unsafe cultural practicesSociodemographic RF◦Arise from mother and her family
◦Lack of prenatal care, low income, marital status (ex: single), and ethnicity: may effect maternal and morbidity rateenvironmental RF◦Hazards in workplace and woman's general environment
◦May include chemicals, anesthetic gases, and radiationAntepartum Testing:Biophysical Assessment:
Daily fetal movement count (DFMC)◦Used to monitor fetus in pregnancies complicated by conditions that may affect oxygenation
◦All moms should understand DFMC.
◦Also called "kick counts"
◦Several different protocols are used for counting (See Figure 10.1)
◦A count of fewer than three kicks in 1 hour warrants further evaluation by a nonstress test (NST).
◦Fetal alarm signal = No movement for 12 hours: go to hospital to get a stress test done
◦baby won't move as much while sleeping (cycles 30-40 minutes)
◦quickening: 16-20wks
◦@28wks daily fetal kick count: for 1 hr observe baby movement (at least 3)
◦by 3rd trimester: at least 3 kicks per hourAntepartum Testing:Biophysical Assessment:
Ultrasonography◦Levels of ultrasonography
◦Methods: bounce sound waves off baby
-Abdominal
-Transvaginal: done in 1st trimester, fetal wellbeing and due date
◦Indications for use
-Fetal heart activity
-Gestational age
-Fetal growth: may be done if wt gain not on track or fundus size alarming
-Fetal anatomy: neural tube defects
-Varies by trimesterUltrasonography: Indications for use-Fetal genetic disorders and physical anomalies
-Placental position and function
-Adjunct to other invasive tests (Amniocentesis, PUBS, CVS)Fetal Genetic Disorders: seen on ultrasoundNuchal translucency (>3mm fluid collection in the nape of the fetal neck) between 10-14 weeks may be an indicator of chromosomal anomalies (Tri 13, 18 and 21) if it appears with maternal serum marker levels. When it appears alone it can be an indicator or cardiac anomalies.
Other Genetic markers: Nasal bone length, short femur or humerus, echogenic bowel, echogenic intracardiac focus, dilation of the renal pelvis are soft markers for trisomies. If these are detected then women should be referred for Amnio.
Placental position and function: Placenta previa may be diagnosed, depending upon gestation. Placenta may appear to be covering the cervical os in second trimester but will migrate up.
Also useful for placental aging in postterm pregnancies, detection of calcifications and poor circulation.Ultrasonography: fetal well being-Doppler blood flow analysis: 15wks
-Amniotic fluid volume: (>5 cm and <25 cm)
-Biophysical profile (BPP)
Modified biophysical profileBiophysical ProfileFetal Breathing Movements
Fetal Movements
Fetal Tone
Amniotic Fluid Index (AFI)
Non stress Test
-8-10: normal
-<8: intervention needed
-<5-6: may need to deliver the babyNonmedical ultrasounds3-D and 4-D increasingly popular with pregnant women and their families
-not done by medical professionalsAntepartum Testing: Biophysical Assessment
Magnetic resonance imaging◦Noninvasive radiologic technique
◦Examiner can evaluate the following:
-Fetal structure, overall growth
-Placenta
-Quantity of amniotic fluid
-Maternal structures
-Biochemical status of tissues and organs
-Soft-tissue, metabolic, or functional anomalies
◦not the best bc it's a long process and baby doesn't always stay still
◦non contrast testBiochemical assessment = biologic examination and chemical determinations◦Procedures used to obtain the needed specimens include amniocentesis, percutaneous umbilical blood sampling (PUBS), chorionic villus sampling (CVS), and maternal sampling
*Administer Rhogam to mothers with negative blood types.Antepartum Testing: Biochemical Assessment
Amniocentesis-obtains amniotic fluid
-After 14 weeks gestation. Done under ultrasound guidance. Transabdominal introduction of a needle into the uterus and amniotic fluid is withdrawn for analysis.
◦Potential complications: amniotic fluid embolism, maternal hemorrhage, water breaking, miscarriage
◦Indications for use
-Genetic concerns
-Fetal maturity
-Fetal hemolytic disease
*Administer Rhogam to mothers with negative blood types after procedureAntepartum Testing: Biochemical Assessment
Chorionic villus sampling◦Technique for genetic studies
◦taken from trophoblasts in the placenta between fetal and maternal areas of gas exchange
◦Earlier diagnosis, rapid results
◦Performed between 10 and 13 weeks of gestation
◦Involves removal of small tissue specimen from fetal portion of placenta
◦Transcervically or transabdominally
◦can't determine lung maturity from this
◦risks: amniotic fluid embolism, maternal hemorrhage, water breaking, miscarriage
*Administer Rhogam to mothers with negative blood types.Antepartum Testing: Biochemical Assessment
Percutaneous umbilical blood sampling (PUBS) (also called cordocentesis)◦Direct access to the fetal circulation during the second and third trimesters: test done to assess for anemia and leukocemia, fetal infection, thrombocytopenia
◦This procedure has been replaced in many centers by placental biopsy.: blood from umbilical cord
◦Insertion of needle directly into fetal umbilical vessel under ultrasound guidance
-RF: preterm birth, damage to fetus, bleeding at site, bradycardia
-RF mom: hemorrhage, amnioniocitisAntepartum Testing: Biochemical Assessment
Maternal assays: ◦Maternal serum alpha-fetoprotein (MSAFP)-Maternal serum levels used as screening tool for neural tube defects (NTDs) in pregnancy: measure maternal serum between 16-18wks (range 15-20wks)
-Detects 80% to 85% of all open NTDs and open abdominal wall defects early in pregnancy
-Screening recommended for all pregnant women
-AFP levels must be correlated with gestational age, maternal age, weight, race, presence of multifetal pregnancy, presence of insulin dependent diabetes.
-16-18wks gestation to assess if body has neural tube defects
-Not dx, ultrasound used for diagnosis
*high risk for false positivesMultiple Marker Screens: First Trimester-First Trimester: 11-14 weeks; 3 hormones
-First Trimester: 8-10 weeks
ADAM 12Multiple Marker Screens: Second & Third Trimester-Triple Screen: b/w 16-18 weeks
-Quad Screen: b/w 16-18 weeks (done more often)
*both dx by amniocentesisAntepartum Testing: Biochemical Assessment
Maternal assays: Coombs' test-Screening tool for Rh incompatibility
-Follow up with amniocentesis or middle cerebral Doppler studies to assess degree of hemolysis
-Detects other antibodies that may place fetus at risk for incompatibility with maternal antigens
-doppler can now be used
*direct: test drawn on baby
*Indirect: test drawn on momAntepartum Testing: Biochemical Assessment
Maternal assays: Cell-free DNA screening in maternal blood-Noninvasive prenatal genetic testing (NIPT): looking at maternal blood for number of genetic amounts bc we already know mom has a normal chromosome amount
-Provides definitive diagnosis noninvasively for fetal Rh status, fetal gender, and certain paternally transmitted single gene disorders
-Screening for aneuploidy (Trisomies): 13, 18, 21 (but not dx)
-Performed as early as 10 weeks of gestation
-Results are usually available in about 10 business days
-Genetic screening test only- Amniocentesis or CVS should be done for confirmation.Fetal Care CentersFetal care centers:
◦provide diagnostic and therapeutic options as well as support services for families with a fetal anomaly diagnosis.
-Access to support services:
◦genetic counseling
◦social work
◦chaplain services
◦palliative care team
◦ethics consultation because of complex emotional stressorsAntepartum Assessment Using Electronic Fetal MonitoringIndications
◦Does the intrauterine environment continue to support the fetus?
Nonstress test
◦Procedure: electronic fetal monitor for 20 minutes and count number of acceleration or decelerations as well as variability and HR baseline
◦Interpretation: reactive or nonreactive
-reactive is good! non reactive is not our favorite but it's possible baby's asleep
Vibroacoustic stimulation: used to awake up a baby is they are asleep
Contraction stress test
◦Procedure
-Nipple-stimulated contraction test
-Oxytocin-stimulated contraction test
◦Interpretation
-Reactive stress test: reacts to the contraction
-(-) result: no baby late cardiac deceleration; this is what we want
-(+) results: late deceleration present, HR decreased after contraction
-Reactive NSTs and negative CSTs suggest fetal well-being.Bony pelvisProtection of pelvic structures, accommodation of the growing fetus during pregnancy, and anchorage of the pelvic support structures.Barriers to entering health care system-Financial issues: racial and socioeconomic disparity
-Cultural issues: constantly changing demographics
-Gender issues: sexual orientationMenarche-Onset of menses, median age is 13
-structure, timing, hormone levels: all must be intact and functioning in order for menstrual cycle to regulate
-menstruation: periodic uterine bleeding that begins approximately 14 days after ovulation
-average blood loss: 50 mLS/sx of breast cancer-hard, fixed lump
-irregular borders
-nipple discharge
-discoloration
-unilateralBacterial STIchlamydia, gonorrhea, syphilis, PIDReportable STIschlamydia, gonorrhea, syphilis, chancroid, lymphogranuloma venereum, granduloma inguinaleViral STIHPV, Herpes, HIV, hepatitis A,ContraceptionIntentionally preventing pregnancy from occurringSpermatogenesis-men are pretty much always fertile
-process starts at puberty and goes throughout lifeOogenesis-1st division starts fetal development and remains suspended for years until first ovulation
-time suspension might be why older women are more likely to have babies with DS or other trisomy (non-disjunction error)Ultrasound for genetic anomaliesMeasure nasal bridge
-absent: trisomy
Nuchal translucency with trisomy
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