OBS GYN

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OBS / GYN

• By Nancy Bergeron, Rosemarie Hoffman, Lark
  Hunter-Bonnah, Shanena Powers, Julie Thomas

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Case Study

• Kimberly Allen is a 42 year old woman who is
  pregnant for the first time. She is working full
  time but she and her partner, Jennifer Way, are
  just making ends meet with the expenses for IVF.
  Kimberly is an average height obese woman
  Jennifer is a tall thin woman. When they decided
  to have a child it was discovered that Jennifer
  has endometriosis and fibroids and can not get
  pregnant therefore Kimberly will be carrying the
  child.

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Primigravida Advanced Maternal Age

• When a woman delays having children until after
  age 35

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Primigravida Advanced Maternal Age

• ? rates of cardiovascular disease, diabetes,
  obesity, uterine leiomyomata, multiparity
• ? risk of hypertensive disorders of pregnancy,
  gestational diabetes, caesarean delivery and
  maternal mortality
• ? risk of chromosomal or congenital abnormalities
• ? perinatal mortality
• ? risk of assisted reproductive technologies,
  including oocyte donation
• ? likelihood of PICU services

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Primigravida Advanced Maternal Age

• Can influence mother-fetus relationship with
  negative effect on development and predisposition
  to diseases such as type 1 diabetes and could
  bring about changes in the genetic composition of
  a population
• Outcomes generally good, with significantly ? in
  rate of caesarean sections
• An ? risk of stillbirth and unexplained fetal
  death, and preterm delivery

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Primigravida Advanced Maternal Age

• Many women are unaware of potential consequences
  of delayed childbearing
• There are missed opportunities in preconception
  counselling and education, which should be
  addressed to allow for more informed
  decision-making about family planning

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Advantages of Delayed Childbirth

• Psychosocial maturity
• Self-confidence
• Sense of control over life
• Capable of solving complex problems
• Maintaining interpersonal relationships
• Financial security
• Experience at setting priorities and developing
  plans
• Stress management techniques
• Will seek support and assistance when needed

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Disadvantages of Delayed Childbirth

• Need more time to recover from birth
• Less energy
• Child care exhausting at first, particularly
  after caesarean
• Peer support may be less available, many friends
  may have teenagers and do not relate to newborn
  concerns
• Family support may be lacking as parents are
  older and may be unable to help with child care

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Endometriosis
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What is Endometriosis?

• Growth of cells outside uterus
• Shed during menstruation
• Called implants
• Found on ovaries, fallopian tubes, intestines,
  and lining of pelvic cavity
• Vagina, cervix, and bladder
• Can occur outside the pelvis
• Are benign

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Who is affected by endometriosis?

• Women in their reproductive years
• Over one million women in US
• One of leading causes of pelvic pain and reasons
  for laparoscopic surgery and hysterectomy
• Diagnosed around 25-35 yrs
• More common in white women
• Most common in tall, thin women with low BMI
• Delaying pregnancy also believed to increase risk
  of developing endometriosis

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Theories about causes

• Tissue is deposited in unusual locations by
  retrograde menstruation
• Primitive cells that grow into other forms of
  tissue
• Direct transfer of tissues during surgery
• Transfer via bloodstream or lymphatic system
• Alternations in immune response may affect body's
  natural ability to recognize and destroy any
  misdirected growth of endometrial tissue

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What are endometriosis symptoms?

• Most women do not have symptoms
• Pain (usually pelvic) and infertility
• Pain - during or just before menstruation and
  lessens after
• Pain depends partly on where implants are located
• Pain can result when implants form scars
• Can be reason for infertility

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What are endometriosis symptoms?

• Infertility but might be d/t both anatomic and
  hormonal factors
• tissue or scarring in pelvis may distort normal
  structures
• hormones and other substances have negative
  effect on ovulation, fertilization and/or
  implantation
• Other symptoms
• lower abdominal pain
• diarrhea and/or constipation
• low back pain
• irregular or heavy menstrual bleeding
• blood in urine
• Rare SS - chest pain or coughing blood, and
  headache and/or seizures

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Endometriosis and cancer risk

• Women with endometriosis have a mildly ? risk for
  development of certain types of cancer of the
  ovary
• This risk seems to be highest in women with
  endometriosis and primary infertility, but the
  use of oral contraceptive pills, which are
  sometimes used in the treatment of endometriosis,
  appears to significantly reduce this risk

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How is endometriosis treated?

• Endometriosis can be treated with medications
  and/or surgery
• The goals of endometriosis treatment may include
  pain relief and/or enhancement of fertility

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Treatment of infertility

• Usually does not fully prevent conception,
  especially in mild to moderate cases
• Infertility is more common in women with severe
  forms of disease
• Treatments are varied
• Surgical treatments are superior to hormonal or
  medical treatments when goal is enhanced
  fertility
• Assisted reproduction may be used

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Fibroids

• What are they
• Who is Susceptible
• Who is affected most

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Uterine Myomas (fibroids)

• Occur with greater frequency in women older than
  35 years and may be associated with postpartum
  hemorrhage

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Uterine Myomyomas/Leiomyomas

• Body parts affected
• Symptoms
• Prevention
• Complications/Pregnancy
• Menopause

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Leiomyoma

• Subserous, submucosal, intramural
• Diagnosis
• Interventions/treatment alternatives
• Hysteroscopic resection
• Laparoscopic Myomectomy
• Laparoscopic myolysis
• Laparoscopic cryomyolysis
• Uterine artery embolization

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LEIOMYOMAS/Myomyomas
Uterine fibroids
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Case Study

• After being unsuccessful with artificial
  insemination, the couple opt for in vitro
  fertilization, Kimberly is successful with IVF
  therapy on the first attempt.

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IVF

• In vitro fertilization
• Successfully used in 1978

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IVFWho May Benefit?

• Women who have a blocked or damaged fallopian
  tube
• Mild problem with male partners sperm
• No cause identified for inability to conceive
• Patients who have tried IUI or ovulation
  induction with no success

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IVFProcedure

• Fertility drugs
• -gonadotrophin-releasing hormones (GnRH)
• -human-menopausal gonadtrophin (hMG)
• -human chorionic gonadotrophin (hCG).
• Monitor blood hormone levels
• Ultrasound scan
• Remove ova through ultrasound-guided transvaginal
  retrieval or laparoscopy

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IVF Procedure Contd

• Eggs are mixed with sperm in dish and cultured in
  incubator
• Dish checked in 2 days to see if eggs have been
  fertilized
• Those kept are kept for a couple more days and
  checked again
• Fertilized eggs form ball of cells-embryo
• Healthiest embryo is inserted into uterus
• Taking progesterone all along to thicken lining

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IVF Procedure Contd

• Progesterone given by injection, pessary or gel
• Endometrium too thin IVF cycle abandoned
• Two embryos transferred with thin catheter
  through cervix into uterus (ultrasound)
• No more then three embryos can be legally
  transferred
• Number of embryos transferred depends on your age
  and chances of success
• If successful able to take a pregnancy test in 2
  weeks

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IVF

• IVF treatment takes 4-6 weeks to complete
• Success rates vary
• Advantages gives women with blocked, damaged or
  missing fallopian tubes a chance to have a baby
• Disadvantages increased chances for multiple
  births, increase risk for miscarriage and other
  complications, hormones not closely monitored
  lead to ovarian hyperstimulation syndrome,
  ectopic pregnancy

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MULTIPLE PREGNANCY
Multiply pregnancy occurs when the use of
ovulation inducing medication triggers the
release of multiple eggs, which, when fertilized
produce multiple embryos that are then implanted
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Case Study

• The couple live in a small hamlet about half an
  hour from the city.
• Our medical clinic arranges for Kimberlys
  prenatal care and any tests and assessments she
  may need for the duration of her pregnancy and
  delivery.

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Tests during pregnancy

• Initial visit
• Obtain Client profile
• Current Pregnancy
• Past Pregnancies
• Gynecological Hx
• Current Medical Hx
• Past Medical Hx
• Family Medical Hx
• Religious, spiritual and cultural Hx
• Occupational Hx
• Partners Hx
• Personal Info about Pt
• High Risk screening
• Kimberlys Risk factors
• Weight
• Maternal Age
• Possible Multiple gestation due to IVF
• Medical disorders Gestational Diabetes

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Prenatal Tests

• Prenatal assessment
• Pregnancy test
• Ultrasound
• Vital signs
• Full physical assessment
• Urine sample
• Proteins
• Glucose
• Pelvic exam
• Height of fundus
• Lab evaluation
• CBC and blood typing, Rh factor
• STD tests and Immunity status

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First Trimester Prenatal Screening Tests

• First trimester screening is a combination of
  fetal ultrasound and maternal blood testing
• Ultrasound for fetal nuchal translucency (NT)
• Maternal Serum Screening (blood) (2 tests)
• pregnancy-associated plasma protein screening
  (PAPP-A) - a protein produced by the placenta in
  early pregnancy. Abnormal levels are associated
  with an increased risk for chromosome
  abnormality.
• human chorionic gonadotropin (hCG) - a hormone
  produced by the placenta in early pregnancy.
  Abnormal levels are associated with an increased
  risk for chromosome abnormality.

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First Trimester Testing

• When used together as first trimester screening
  tests, nuchal translucency screening and maternal
  blood tests have a greater ability to determine
  if the fetus might have a birth defect, such as
  Down syndrome, trisomy 18, or trisomy 13.
• If the results of these first trimester screening
  tests are abnormal, genetic counseling is
  recommended. Additional testing such as chorionic
  villus sampling, amniocentesis, or other
  ultrasounds may be needed for accurate diagnosis.

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Second Trimester Prenatal Screening Tests

• Second trimester prenatal screening may include
  several blood tests, called multiple markers. 
• AFP blood test is also called MSAFP (maternal
  serum AFP).
• Abnormal levels of AFP may signal the
  following
• open neural tube defects (ONTD) such as spina
  bifida
• Down syndrome
• other chromosomal abnormalities
• defects in the abdominal wall of the fetus
• twins - more than one fetus is making the protein
  
• a miscalculated due date, as the levels vary
  throughout pregnancy
• hCG - human chorionic gonadotropin hormone (a
  hormone produced by the placenta)
• estriol - a hormone produced by the placenta
• Inhibin - a hormone produced by the placenta

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Integrated Prenatal Screening

• You have a choice
• Testing
• IPS replaces maternal screening
• 4/100 positive test
• 96 /100 negative test

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Integrated Prenatal Screening

• Flow chart
• Discuss IPS before 13 weeks
• U/s done followed by blood test 11-13 weeks
• 2nd Blood test done 15 to 16 weeks
• IPS result at 16 to 17 weeks

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OBESITY and PREGNANCY

• Risk for Mother
• Preeclampsia
• Gestational Diabetes
• Cesarean Section
• Higher incidence of anesthetic and postoperative
  complications

• Risk for Baby
• Lower Apgar score
• Macrosoma
• Neural Tube Defects
• Childhood Obesity

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Nursing implication of Obese and pregnant patient

• Having the needed equipment ready when the woman
  is admitted reduces the embarrassment the woman
  might feel if staff are searching to find
  appropriate materials, E.g. such as blood
  pressure cuffs that fit.
• Need the patients accurate weight for Dosage
  Calculation  
• The women should be asked what position is most
  comfortable. Extremely obese women are often not
  placed in stirrups or traditional lithotomy
  position but rather in a side-lying position for
  birth. .
• Some birthing units call for a bariatric bed in
  anticipation of the admission of an extremely
  obese woman
• Fetal heart monitors
• OR tables
• Nurses need to maintain nonjudgmental attitude
  during preplanning and hospital care of the
  extremely obese woman

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Case Study

• It is discovered during the routine urine test
  that Kimberly has glucose in her urine,
  indicating further testing is needed. Kimberly is
  then sent for a glucose tolerance test along with
  the other lab tests ordered by her doctor.
• It is found that Kimberly has high blood sugar
  levels and is diagnosed with Gestational
  diabetes. She is placed on diabetic diet and
  routine testing of her glucose levels daily. The
  baby will also be monitored for growth because of
  risk factors related to his mothers diabetes.

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GESTATIONAL DIABETES
Gestational diabetes is glucose intolerance that
is diagnosed during pregnancy. Gestational
diabetes often goes away after the baby is born
Complications of gestational diabetes A woman
with gestational diabetes is at increased risk
for preterm birth cesarean birth
stillbirth hypertension developing type 2
diabetes postpartum. The baby of a woman with
gestational diabetes is at increased risk for
macrosomia shoulder dystocia hypoglycemia
jaundice respiratory distress syndrome low
calcium and magnesium levels childhood and
adult obesity (especially if baby is macrosomic),
which can lead to type 2 diabetes
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MONITORING GESTATIONAL DIABETES DURING PREGNANCY

• Eat a balanced diet
• Regular exercise
• Monitor blood glucose levels
• Monitor fetal growth and well being
• Have regular medical check-ups
• Take insulin injections if needed

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SCREENING FOR GESTATIONAL DIABETES

• The one-step approach
• After her fasting blood glucose level is
  measured, the patient drinks 75 grams of glucose.
  Her blood is then drawn at intervals 1 and 2
  hours after drinking the glucose.
• Diagnostic criteria for gestational diabetes
  using the one-step approach
• Fasting 95 mg/dL or more
• 1 hour 180 mg/dL or more
• 2 hours 155 mg/dL or more

The two-step approach 1) Patient drinks 50
grams of glucose then blood is drawn for
testing 1 hour later. If blood glucose value is
130 mg/dL. Proceed to second step, 2) Patient
drinks 100 grams of glucose. Blood is drawn to
measure the glucose level at intervals 1, 2, and
3 hours after drinking the glucose. Diagnostic
criteria for gestational diabetes using the
two-step approach Fasting 95 mg/dL or more
1 hour 180 mg/dL or more 2 hours 155 mg/dL or
more 3 hours 140 mg/dL or more
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Case Study

• Kimberly is 18 weeks pregnant and because of her
  advanced maternal age, and other risk factors,
  she and her partner, with advice from their
  doctor, decide to have an Amniocentesis. The
  procedure is performed without incident other
  than some light cramping. Two weeks later the
  results are in and it shows no abnormalities.

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Amniocentesis

• What is an amniocentesis?
• The doctor obtains a sample of amniotic fluid
  from the mothers uterus and sends it to a
  laboratory to see whether the baby has any
  serious chromosomal abnormalities.
• Using ultrasound for guidance, the doctor will
  identify a pocket of amniotic fluid a safe
  distance from both the baby and the placenta.
• She will then insert a long, thin, hollow needle
  through the abdominal wall and into the sac of
  fluid around the baby.

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What risks are associated with Amniocentesis?

• Infection
• Leakage of amniotic fluid or blood
• Miscarriage

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Amniocentesis

• What kinds of abnormalities can it detect?
• Several hundred genetic disorders
• Chromosomal disorders such as Down's syndrome,
  trisomy 18, and Edward's syndrome
• Neural tube defects such as spina bifida and
  anencephaly.
• RH status of baby and mother
• whether the baby's lungs are mature.
• Cannot detect every kind of abnormality

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Amniocentesis

• An Amniocentesis is usually performed between the
  15th and 18th weeks of pregnancy.
• By the second trimester, there is enough amniotic
  fluid surrounding the baby to make it easier for
  the doctor to take an adequate sample without
  putting the baby at risk.
• Procedure
• With the needle, the doctor withdraws a small
  amount of amniotic fluid -- about an ounce, or
  two tablespoons. This fluid contains cells from
  the baby, chemicals, and micro-organisms.
• Nursing Considerations
• Monitor mother for uterine contractions and to
  listen fetal heart-rate to asses for fetal
  distress.

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Trisomony 21

• Also called Downs Syndrome
• Specific characteristics
• Chromosome abnormality
• Genetic testing

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Case Study

• While Christmas shopping Kimberly slips on some
  ice while walking back to her car in the parking
  lot, she stumbles and falls while twisting and
  catching herself on one wrist. She thinks she is
  fine and goes home to rest. A few hours later she
  wakes up with cramping thinking she has pulled a
  muscle in her side. She takes a Tylenol and goes
  back to sleep. She gets up later to void and
  notices blood in the toilet bowl. She tells
  Jennifer and they both freak out. They phone
  telehealth who advises them to call an ambulance
  to go to their closest emergency department.

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Telehealth Ontario

• Free telephone service which provides access to a
  nurse who can assess and provide recommendations
  for callers who require health advice or general
  health information
• Available 24/7
• Phone [phone]

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Case Study

• After waiting 15 minutes Jennifer gets scared
  because Kimberly is only 30 weeks pregnant, and
  decides they can not wait for the ambulance and
  bundles Kimberly into their car to drive her to
  the hospital.
• After driving only 15 minutes, Kimberlys water
  breaks. The cramping intensifies and they now
  recognize the cramps as contractions.
• A few minutes later Kimberly says she feels
  something coming out. On investigation they find
  what they think is part of the umbilical cord
  protruding from the birth canal.
• While driving, they time the contractions, when
  they arrive at the hospital the contractions are
  5 minutes apart.

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Case Study

• At the triage desk the nurse quickly takes
  Kimberly into a room, Jennifer is told to stay
  and do the paperwork. Kimberly is assessed, it
  is found that the umbilical cord is protruding.
  Kimberlys vital signs are stable and she is put
  into a knee-chest position, with her thighs at
  right angles to the bed and her chest flat on the
  bed and immediately sent up to the labour and
  delivery unit, she is currently at 30 weeks
  gestation. In the labour unit the doctors
  assessment shows that Kimberly is too far effaced
  and dilated to consider any drugs to stop the
  labour. The fetal heart monitor shows the baby
  is distressed. Because it is so early the baby
  is in the breach position and an emergency
  c-section must be performed.

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Preterm Birth
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Premature Rupture of Membranes

• Rupture of the amniotic sac before the onset of
  true labour regardless of length of gestation.
• Possible causes
• Infections of vagina or cervix
• Amniotic sac with a weak structure
• Chorioamnionitis
• Hydramnios
• Fetal abnormalities of malpresentation
• Incompetent cervix
• Over-distension of uterus
• Maternal hormone changes
• Recent sexual intercourse
• Maternal stress
• Maternal nutritional deficiencies
• Trauma

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Preterm Labour
Labour that begins after the 20th week but before
the 37th week of pregnancy

• Associated factors
• Maternal medical conditions
• Conception assisted by reproductive technology
  including those that result in a single fetal
  gestation
• Present and past obstetrical conditions
• Fetal conditions
• Social and environmental factors
• Demographic factors

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Signs and Symptoms

• Uterine contractions
• Cramps similar to menstrual cramps
• Constant low back pain
• Pelvic pressure
• Pain or discomfort in pelvic area or thighs
• Change or increase in discharge
• Abdominal cramps with or without diarrhea
• Sense of feeling bad or coming down with
  something