Transcript OB Review #1

OB Review #1
Functions of the Female Reproductive System
Produce ovum, Maintain the fertilized egg, Maintain the embryo
Structures:
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Ovaries: Have 2 main functions: Ovulation and production of
hormones (estrogen & progesterone)
Uterus: is peared shape and measures approx 3 inches. Receives and
nurtures embryo during development
Fallopian Tubes: convey ovum to uterus
Fimbrae: fingerlike projections lined by tiny hair like cilia that assist
the ovum to travel to the uterus.
Three Phases during Menstrual Cycle
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Proliferative Phase:
Preparing for Ovulation endometrium begins to grow
after menstruation.
Secretory Phase: Preparing
for Implantation - endometrium
is becoming ready for the
implantation of a blastocyst.
Menstrual Phase: If no
implantation occurs, the
endometrium breaks down
and is discharged in
menstruation.
Proliferation Phase: Preparing….
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Proliferation Phase starts in the anterior pituitary
gland with the release of FSH (follicle stimulating
hormone)
FSH goes to the ovaries and causes the ovarian
graafian follicle (OVUM) to develop/mature & ripen.
Follicle begins to mature - releases ESTROGEN
Estrogen causes the uterine lining to thicken in
preparation of the ovum (egg) and causes the ovum
to ripen and enlarge.
When estrogen levels get high enough they cause
the release of LH or luteinizing hormone
Premenstrual Syndrome - PMS
PMS often occurs after ovulation.
 Over 150 symptoms have been reported
that have been related to PMS.
 Treatment includes
 Counseling
 Medications: NSAIDs
 Dietary changes: low sodium, caffeine,
chocolate.
 Regular exercise: relaxation techniques
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Candidiasis Vaginitis (yeast)
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White thick curdy discharge
Vaginal itching, burning
Vaginal culture, wet mount
Treatment: vaginal creams Minonazole, Monistat-3,
Monistat-7, Nystatin
Oral – diflucan
Prevention: avoid tight fitting
clothes.
Antibiotic therapy or hormonal
Yogurt
No douching
Ovarian Cancer
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Originates in epithelial
tissue of ovary.
May not produce
symptoms until it is in
an advanced,
inoperable stage.
Survival Rate
Treatment includes a
combination of
surgery, radiation,
chemotherapy,
immunotherapy, and
palliation.
Endometriosis
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Growth of
endometrial tissue
outside the uterus
within the pelvic
cavity.
Cause is unknown
Symptoms include
low backache,
painful intercourse,
a feeling of
heaviness on the
pelvis, and spotting
or heavy bleeding
Infertility due to scar
tissue
Cervical Cancer
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The most preventable
gynecological cancer,
with regular Pap smears.
Most common signs:
abnormal bleeding, odor,
pain in lower back, groin,
difficulty in voiding,
hematuria, rectal
bleeding.
Treatment includes
varying degrees of
surgery, radiation or
radium Implants and
palliation
Radiation Therapy/Radium Implants
May be ordered before surgical excision of
the cervix
 Pregnant or female nurses of childbearing
age should not care for the patient or
spend extended periods at the bedside.
 Direct patient care should be organized.
 Limit time spend at bedside
 Warning Sign should be hung on the door.
 Complete bed rest
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Fibroid Tumors
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Benign tumors growing in
or on uterus.
Symptoms include
menorrhagia, increasing
pelvic pressure,
dysmenorrhea, abdominal
enlargement, and
constipation.
Treatment: periodic
reexamination,
myomectomy, or
hysterectomy.
Prolapsed uterus
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Downward displacement of
the uterus into the vagina.
Factors – multiple vaginal
deliveries, large infant,
Increasing age, frequent
heavy lifting. A number of
conditions, constipation, and
obesity.
Symptoms - Urinary
complaints including urinary
incontinence frequency,
urgency, pain with
defecation, constipation, or
incontinence, sexual
complaints, including pain
with intercourse.
Dx: Examination, Ultrasound,
MRI
Tx: kegel exercise, pessaries,
surgery
Uterine Prolapse Degrees
1st degree: cervix visible at vaginal
opening
 2nd degree: cervix extends beyond the
vaginal opening
 3rd degree: uterus protrudes outside of the
vagina.
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Pelvic Inflammatory Disease (PID)
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Inflammation of fallopian
tubes, ovaries, or both, along
with vascular and supporting
structures within the pelvis,
except the uterus.
Symptoms include fever,
pelvic pain, foul-smelling
vaginal discharge, pain
during sexual intercourse,
and nausea.
Bacterial: (streptococcus,
staphylococcus, gonococcus,
Chlamydia
Viral: Herpes simplex virus 2
Treatment: antibiotic therapy,
bed rest. Hospitalization for
IV medications for severe
cases.
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Also called chronic
cystic mastitis.
Symptoms include
lumps that are single or
multiple cysts, frequently
fluid-filled.
Fibrocystic areas may
mask areas of breast
cancer.
BSE.
Aspiration or surgical
excision may be
indicated.
TX: Danazol (X)
Vitamin E
No caffeine
Fibrocystic Breast
Disease:
Breast Cancer Stages
1: tumor <2cm, no lymph nodes, no
metastases
 2: tumor 2 – 5cm,0-1 lymph nodes + ca,
no metastases
 3: tumor >5cm, lymph nodes +ca, no
metastases or tumor 0-5cm, +ca lymph
nodes, no metastases
 4: tumor any size, may/may not test +ca,
metastases to lungs, bone, brain, liver
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Modified Mastectomy
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A surgical procedure to
remove the whole breast
that has cancer, many of
the nearby lymph nodes
under the arm.
Chest wall muscle is not
removed.
Dotted line shows entire
breast and some lymph
nodes are removed.
Lumpectomy and Partial Mastectomy
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Partial Mastectomy: A
surgical procedure to remove
the part of the breast that
contains cancer and some
normal tissue around it.
Lumpectomy: A surgical
procedure to remove a tumor
and a small amount of
normal tissue around it.
Dotted lines show area
containing the tumor that is
removed and some of the
lymph nodes that may be
removed.
Structural Male Disorders
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Hydrocele–a benign,
nontender collection of fluid
within the space of the
testes and the spermatic
cord.
Spermatocele–benign
nontender cyst of the
epididymis.
Variocele–dilation of veins
of the scrotum.
Torsion of the spermatic
cord–twisting of the
vascular pedicle of the
testis.
BENIGN PROSTATIC HYPERPLASIA (BPH)
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Enlargement of
prostate gland that
occurs with aging.
Treatment includes
medications, balloon
dilation, urethral stent,
thermotherapy, and the
transurethral resection
(TURP).
If no treatment:
Infection, Renal failure
and urinary obstruction
Symptoms of BPH
• Urgency of urination
• Frequency of urination
• Abdominal straining
• Nocturia
• Impairment of size and
force of stream
• Intermittent hesitancy
• Incomplete bladder
emptying
• Terminal dribbling
• Dysuria
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A resectoscope inserted through the urethra, for the treatment of
BPH. A wire loop cuts away prostate tissue and seals blood
vessels with an electric current.
TURP
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Assesses the patency of
inflow and outflow
tubing, rate of irrigation,
and bladder distention
by palpation.
Hang irrigation solution
bag no higher than 2 – 3
feet above level of the
patient’s bladder.
0.9% sodium chloride
solution is used for
irrigation.
Prostate Screening
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Digital rectal exam:
(DRE) is an exam of the
rectum.
A rectal exam to examine
the the prostate for
lumps or anything else
that seems unusual.
Prostate-Specific
Antigen (PSA): prostate
cancer screen. High PSA
level: These include
urinary tract infections,
benign prostatic
hyperplasia (BPH) and
prostatitis. normal range
<4 ng/ml..
Penile Cancer
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Bacteria harbored in foreskin of uncircumcised male
are irritants to glans penis and prepuce, thought to
be carcinogenic.
HPV causative factor
Symptoms: itching/burning on penis, painless,
nodular growth on foreskin, fatigue, weight loss.
The primary treatment is surgery.
TX: Surgical procedure, cryotherapy,radiation
therapy
Prevention: Circumcision, condom use, smoking
cessation.
Male Inflammatory disorders
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Epididymitis: inflammation
of epididymis.
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Orchitis is inflammation of
testes.
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Bilateral: sterility
Infection or trauma
Prostatitis is inflammation
of prostate.
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Sterile and Nonsterile:
Bilateral sterility
Untreated: necrosis,
septicemia and death
Chlamydia or gonorrhea
Treatment for all includes
antibiotics, bed rest,
scrotal support, and ice to
the area.
Process of Reproduction
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Fertilization refers to the joining together of the
ovum and sperm cells.
Only one sperm is required for actual fertilization.
The union between ovum and sperm occurs in the
outer third of the fallopian tube.
The ovum and sperm = Zygote begins rapid cell
division and in 2 to 3 days becomes a structure
referred to as Morula.
The morula is a rapidly growing structure and
reaches the uterus in approximately 4 days.
Pregnancy Test
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Measure hCG (human chorionic
gonadatropin)
 95-98%
 blood
accuracy
and urine tests
Estimated Date of Delivery
Nagele’s rule
 Begins with 1st day of last menstrual
period, subtract 3 months, and add 7 days
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Presumptive Signs & Symptoms of Pregnancy
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Presumptive signs and
symptoms of pregnancy
are those signs and
symptoms that are usually
noted by the patient.
These signs and
symptoms are not proof of
pregnancy but will
suspicious of pregnancy.
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Amenorrhea
Nausea and vomiting
Enlargement & Breast
soreness
Frequent urination
Feeling tired
Montgomery's tubercules
Stretch marks
Spider veins
Quickening (fetal
movement)
Colostrum from breasts
Quickening
This is the first perception of fetal
movement within the uterus.
 It usually occurs toward the end of the fifth
month because of spasmodic flutter.
 A multigravida can feel quickening as early
as 16 weeks.
 A primigravida usually cannot feel
quickening until after 18 weeks.
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Noted by the clinician
upon examination of
the patient:
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Enlarged abdomen
Positive pregnancy test
Change in uterine shape
Softening of the cervix
(Goodell's sign)
Chadwick’s Sign
Enlarging uterus
Braxton Hicks contractions
Hegar’s Sign
Palpation of the baby
Ballottement
Probable Signs
Goodell’s Sign
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Goodell’s sign
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cervix is normally firm like the cartilage at
the end of the nose. The Goodell's sign is
when there is marked softening of the cervix
(due to invreasing vacularity and edema)
 This is present at 6 weeks of pregnancy
Chadwick’s Sign
The vaginal walls and cervix have taken
on a deeper color (blue/violet) caused by
the increased vascularity because of
increased hormones.
 It is noted at the sixth week when
associated with pregnancy.
 It may also be noted with a rapidly growing
uterine tumor or any cause of pelvic
congestion.
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Leopold’s Maneuvers
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Series of hands on
positions by
examiner
Assists in
determining fetal
position
Performed during
prenatal visits.
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Demonstrated
during the
bimanual exam at
the 16th to 20th
week.
The lower uterine
segment or the
cervix is tapped by
the examiner's
finger and left
there
Fetus floats
upward, then sinks
back and a gentle
tap is felt on the
finger.
Ballottement
Braxton hicks contractions
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Painless uterine contractions occurring
throughout pregnancy.
May begin about the 12th week of pregnancy
and becomes progressively stronger.
These contractions will, generally, cease with
walking or other forms of exercise.
Are distinct from of true labor contractions by the
fact that they do not cause the cervix to dilate
and can usually be stopped by walking.
Placental Function
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Transports Oxygen, nutrients, and antibodies to
the fetus by means of the umbilical vein
Removes carbon dioxide and metabolic wastes
from the fetus by the two umbilical arteries
Serves as a protective barrier against harmful
effects of certain drugs and microorganisms
Acts as a partial barrier between the mother and
fetus to prevent fetal and maternal blood from
mixing
Produces hormones essential for maintaining the
pregnancy. (estrogen, progesterone, and human
chorionic gonadotropin (HCG)).
Umbilical Cord
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Lifeline to mom
 2 arteries
 unoxygenated
blood
 1 vein
 oxygenated
 Wharton’s jelly
 Outer covering of
umbilical cord
(protects cord)
Amnion & Chorion
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Amnion: Innermost
membrane that lines the
amniotic space.
It is filled with fluid
At full term, this cavity
normally contains 500 cc to
1000 cc of fluid (water).
Chorion: Outer membrane.
It forms a large portion of
the connective tissue
thickness of the placenta
on its fetal side.
It is the structure in and
through which the major
branching umbilical vessels
travel on the surface of the
placenta
Fetal Development – fetal period 9 week - Birth
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Cardiovascular
 Heart begins to beat day 21
 Heart beat detectable by ultrasound at about >6 weeks
 Heart beat heart at about 10 weeks by doppler
Respiratory
 Surfactant matures by 36th week
 Surfactant permits expansion of the lungs
GI system
 Meconium (tarry stool)
Urinary system
 By 5th month, fetus urinates into amniotic fluid
 2nd half of pregnancy: urine makes up major part of
amniotic fluid
Sexual
 Can identify male/female by 16th week
Age of Viability – Respiratory System
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By 24 weeks the lung cells
begin to produce a
substance called
surfactant.
Surfactant: A substance
composed of lipoprotein
Secreted by the alveolar
cells of the lung
Serves to maintain the
stability of pulmonary
tissue by reducing the
surface tension of fluids
that coat the lung.
Physiologic Anemia of Pregnancy
Blood volume increases gradually by 30 to
50% (1500 ml to 3 units).
 RBC’s increase, but cannot keep up with
the pace of the plasma volume
 Decreased hemoglobin and hematocrit
occur.
 This is called pseudoanemia.
 This explains why the need for iron is so
important during pregnancy.
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Respiratory System
Slight elevation in respiratory rate (18-20 in
pregnancy; 12-20 is normal)
 Nasal stuffiness (1st trimester)
 SOB 2nd trimester
 Dyspnea
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 Estrogen
causes upper respiratory tract to
become more vascular. As capillaries fill,
edema develops in the nose.
Interventions: Use cool air vaporizer
 NO SPRAYS
 Proper position; semi-Fowlers when sleeping.
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Musculoskeletal System
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Changes in gravity
Calcium and phosphorus needs - increase
Later in pregnancy, gradual softening of pelvic ligaments
and joints
Lordosis
 Caused by relaxin and progesterone
 Leg cramps and backache (late pregnancy)
 Good nutrition, rest with legs elevated, wear warm
clothing.
 During leg cramp, pull toes up toward the knee/leg
while pressing down on the ankle.
 Use proper body mechanics; avoid high heels
Gastrointestinal System
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Nausea and vomiting
Gingivitis
Increased saliva
Constipation
Increased gastric acid
(heartburn/pyrosis)
 Causes are due to the
cardiac sphincter
relaxes; increased
progesterone; gastric
displacement; hCG
levels
Factors contributing to
maternal nutritional needs:
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Inadequate nutritional
intake
Pica
Low income
Smoking, alcohol, drugs
Teenagers
Chronic medical
conditions
Short interval between
pregnancies
Depression
Physiological changes during pregnancy
Uterus: Braxton Hicks contractions,
Hegar’s sign.
 Cervix: Goodell’s sign, Chadwick’s sign
 Vagina: vaginal secretions prevent
bacterial infections.
 Breasts: Montgomery Tubercules,
Colostrum
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Psychological Adaptation to Pregnancy
Pregnancy Validation: Accepting the
pregnancy
 Fetal Embodiment: Body Image, baby is
part of her body
 Fetal Distinction: Accepting the baby
 Role Transition: preparing for parenthood
(The nesting stage)
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Lightening
 The
descent of the presenting part of the fetus
into the pelvis. Feels as if the baby is
“dropping”.
 Happens
around the 36th week
Mucus Plug
 The plug of mucus that fills the opening of
the cervix
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 Prevents
bacteria from getting into uterus
Identify 5 assessments of the
pregnant female during return office
visits
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Blood Pressure
Weight total weight gain (25-35 lbs)
Week 1 - 12 = 2-4 lbs
Week 13 – 40 = 1 lb a week
Uterine Size
Edema
Fetal position (Leopold’s Maneuvers)
Fetal Heartbeat
Laboratoy test (urinalysis)
Spontaneous Abortions
A.
B.
C.
D.
Threatened
Inevitable
Incomplete
missed
Inevitable Abortion
If the treatment of threatened abortion is
not adequate or timely, the abortion may
become inevitable.
 In this type of abortion, besides pain and
bleeding there is also dilation of the cervix
of the uterus and the process of expulsion
of the fetus cannot be stopped.
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Nonstress Test (NST)
Result Criteria
 Reactive (normal) In a 20-minute period,
two or more fetal heart rate accelerations
of at least 15 beats per minute above the
baseline heart rate
 Nonreactive (abnormal) No fetal heart
rate accelerations over a 40-minute
period.
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Contraction Stress Test
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High Risk Patient: Diabetic Patient
Method of externally monitoring the fetus.
Measures the ability of the placenta to provide
enough oxygen to the fetus during contractions.
Oxytocin IV or nipple stimulation will be used to
induce contractions.
Oxytocin Challenge Test: IV until 3 uterine
contractions are observed, lasting 40 - 60
seconds, over a 10-minute period.
Electrical Fetal Heart Monitoring
Accelerations: common - normal
 Early Decelerations: vagal stimulation to
the fetal head during a contraction which
push the head toward the pelvis - normal
 Late Decelerations: Utero-Placental
insufficiency (fetal blood flow compromised,
less oxygen!!! - abnormal
 Variable Decelerations: cord compression
nuchal cord, knot, decreased amniotic fluid abnormal
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Normal Assessment Findings
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FHR between 110-160 in gestations 32-40+
weeks
Regular rhythm
Increases in the FHR associated with fetal
movement that return to original rate range
Decreases may be heard
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Early Deceleration
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Occur as a result of vagal stimulation to
the fetal head during contractions which
push the fetal head toward the pelvis.
Normal
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Variable Decelerations
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Result from some type of cord
compression: Nuchal cord, True knot
Decreased amniotic fluid. Abnormal
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3 primary mechanisms by which UCs can
cause a decrease in FHR
Variable
Decelerations
Late
Decelerations
Early
Decelerations
Abruptio Placenta
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Premature separation from wall of uterus of a normally
implanted placenta.
Abnormally short umbilical cord
Abdominal Injury
Sudden loss in amniotic fluid
Abruptio Placenta
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Abdominal pain
Vaginal bleeding
Back pain
Symptoms include a rigid, painful abdomen.
Irreversible brain damage or fetal death may occur if hypoxia is not
reversed quickly.
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Implantation is in lower
uterine segment with
placenta lying over or
very near the internal
cervical os.
Symptoms include
painless bleeding in the
last half of pregnancy.
Treat to maintain the
pregnancy until fetus
mature enough to survive
outside uterus
Placenta Previa
Ectopic Pregnancy
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Abnormal pregnancy that
occurs outside the uterus.
Symptoms include:
Missed menstrual period
Pelvic/Abdominal pain
Spotty vaginal bleeding
Pain in the shoulder
Fainting
nausea
Hyperemesis Gravidarum
Excessive vomiting during pregnancy.
 Physiological and psychological factors
may be involved.
 Treatment goals: control vomiting, correct
dehydration, restore electrolyte balance,
and maintain adequate nutrition.
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Pregnancy Induced Hypertension (PIH)
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Most common hypertensive disorder in pregnancy, after 20
weeks’ gestation.
Only cure is delivery of the baby.
Mild preeclampsia–blood pressure increases 30 mm Hg
systolic or 15 mm Hg diastolic over baseline on two
occasions at least 6 hours apart.
May be asymptomatic
Edema noted in face and hands.
Objectively defined as weight gain of more than 1 pound a
week.
Urine may show 1+ or 2+ albumin.
Proteinuria usually the last of the three classic symptoms
to appear.
PIH
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Severe preeclampsia–blood pressure increases
to 160/110 or higher.
Generalized edema in face, hands, sacral area,
lower extremities, abdomen.
Weight gain may be 2 pounds a week.
Urinary albumin may be 3+ or 4+.
Other symptoms: continuous headache,
dizziness, blurred vision, scotomata, nausea,
vomiting, irritability, hyperreflexia, and epigastric
pain.
Epigastric pain often last symptom identified
before client moves into eclampsia.
Eclampsia
Eclampsia–grand mal seizures.
 Without treatment, the client may die.
 Treat to lower blood pressure, prevent
convulsions, and deliver a healthy baby.
 Magnesium sulfate given to prevent
convulsions.
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Magnesium Sulfate
Respirations must be at least 14/minute.
 Toxicity: Respiratory depression to
paralysis
 Deep tendon reflexes must be kept at
normal response.
 Urine output must be at least 30 cc/hr.
 Monitor serum magnesium level.
1.5 – 3mEq/L
 Calcium gluconate is antidote for
magnesium sulfate–keep at bedside.
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Disseminated Intravascular Coagulation
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Over stimulation of normal clotting process,
occurs as complication of a primary problem.
Pregnancy Induced Hypertension
It can cause fetal death.
Symptom onset sudden: dyspnea, chest pain,
restlessness, cyanosis, and spitting frothy,
blood-tinged mucous.
Underlying cause must be identified and
corrected.
The fetus must be delivered.
IV administration of blood, and other blood
products
Heparin is given continuously.
Oxygen therapy
Fetal Surveillance Gestational Diabetic Client
NSTs done around 26 weeks, weekly
 At 32 weeks - done biweekly with
NST/BPP
 Contraction Stress Test
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Maternal Heart Disease
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The heart must compensate for the normal blood volume
increase and workload
If the cardiac changes are not well tolerated than cardiac
failure can develop
Cardiac output is increased 28 – 32 weeks gestation
Prenatal care visits should be more frequent than usual.
Cardiac problems should be managed with cardiologist
Mortality with pulmonary HTN & pregnancy is more than
50%
Diet: low sodium
Avoiding anemia
Avoid strenuous activity
Monitor for: cardiac failure and pulmonary congestion
Phenylketonuria
Individuals with PKU cannot process a part
of protein called phenylalanine present in
most foods.
 phenylalanine builds up in the bloodstream
and causes brain damage and mental
retardation.
 The characteristic features of maternal PKU
syndrome include: mental retardation,
microcephaly, (IUGR) intrauterine growth
retardation, and congenital heart defects
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TORCH: acronym for maternal infections
Toxoplasmosis (TO) - protozoan infection,
neonatal effects – jaundice, hydrocephalus,
microcephaly
 Rubella (R) - congenital deformities
 Cytomegalovirus (C) - CNS damage to fetus
 Herpes genitalis (H) - Perinatal loss. Fetus
may pick up virus if present in the vagina
during labor - Cesarean Section
 If untreated: abortion, congenital anomalies,
fetal infections, IUGR, preterm labor, mental
retardation, or death.

Hemolytic Diseases



Rh incompatibility–can
only happen when mother
is Rh negative and fetus
is Rh positive.
ABO incompatibility–
problem occurs when
maternal blood enters
fetal circulation.
RhoGam 300mcg IM
given at 28 weeks of
pregnancy and 72 hrs of
delivery (Rh negative,
abortion, ectopic
pregnancy and
amniocentesis).