Maternal Nursing Exam 1 (menstrual cycle, infertility, contraception, fetal development)

menstruation

-LMP = first day of last menstrual period (used to determine pregnancy)

-estrogen spike around age 8-11 causes menarche

-become regular and ovulatory after 1 year

-ovulation occurs, then 14 days later menstruation

-average: cycle = 28 days, bleeding = 3-6 days

endometrial/uterine cycle

1) menstrual phase: shedding of endometrium (except basal layer) via vasoconstriction

2) proliferation: growth of endometrium (lasts from day 5 to ovulation)

3) secretory phase: ovulation to 3 days before menstruation

-progesterone made, endometrium matures and secretes to support ovum

4) ischemic phase: blood supply blocked, endometrium necrotizes to cause bleeding

-E&P drop

hypothalamic/pituitary cycle

-cycle ending causes E&P to drop→hypothalamus makes GnRH→anterior pituitary makes FSH→ovarian follicles develop & make estrogen

-anterior pituitary also is stimulated by GnRH to make LH (day 12)→ovum leaves follicle

-LH peaks around day 13-14 to cause ovulation, then corpus luteum regresses if no zygote is implanted

-E&P drops→menstruation→repeat

ovarian cycle

-FSH causes follicles to mature

-body temp rises, mucus thins & clears, possible pain

-LH causes one follicle & oocyte to mature→ovulation

-empty follicle becomes corpus luteum

—makes E&P, which thicken uterine lining

—peaks 8 days after ovulation

—zygote implants, otherwise corpus luteum is shed

hormones during the cycle

infertility

-unable to conceive after 1 year (6 months if over 35 y.o. or other risk fx)

-increases age 40+

-subfertility = prolonged time to conceive

-primary = never been pregnant; secondary = after having been pregnant before

-fecundity = can carry to term & have a live birth

-40% d/t male, 40% d/t female, 20% unexplained

female infertility

-anovulation

—primary d/t hypothalamus or pituitary gland

—secondary d/t low fat %, thyroid gland, PCOS, etc.

-meds (OCPs, antidepressants, steroids, chemo)

-tubal inflammation, decreased motility, adhesions

-uterine tumors

-decreased cervical mucus

-sperm antibodies

-obesity

-thyroid

male infertility

-gland tumor or trauma

-increased androgens/estrogen/cortisol

-obesity

-testicular disorder

-sperm antibodies

-decreased libido, impotence, ED

infertility treatment

-counsel pt to have intercourse 2-3x/wk, especially day before and day of ovulation

-should wait 2 years after birth to get pregnant again to decrease PP hemorrhage

-tests:

—female: HSG, Chlamydia, laparoscopy, sonography, progesterone, cervical mucus, BBT, hormone analysis, ovulation tests

—male: semen, sperm penetration assay, FSH, testicular biopsy

-Rx: lifestyle, diet, exercise, weight loss, good BGM

—men: loose clothes, lower temp water

—also: meds, ART (IVF, insemination, IUI)

coitus interruptus

failure rate = 96%

fertility awareness

-fertility is the 5-7 days around ovulation

-NFP = avoiding intercourse around 4 days before & after ovulation by tracing menstruation, mucus, BBT (abstain from day one of menstruation until day 3 of temp rise)

—must measure BBT before moving in morning

-calendar rhythm = track cycle length; must track period for 6 mo before

-standard days = fixed number of days; use bracelet

-breastfeeding (LAM) = feeding q4h during day and q6h at night

barrier method

-spermicide (may increase HIV or cause lesions)

—apply 1 hr before

—must contact cervix

—best if used with another method

-condoms (help decrease STIs)

-diaphragm (reusable)

-cervical cap (has spermicide)

—woman must be comfortable touching her cervix

-sponge

OCPs

-decrease flow, reduce anemia, alleviate PMS & dysmenorrhea

-decreases FSH & LH to stop ovulation, thins uterine lining, thickens mucus, may prevent implantation

-contraindicated: thromboembolic issues, CAD, breast CA, tumors, pregnancy (till 6 wk after birth), liver/gallbladder problems, smoking, HTN, migraines w/ aura, DM, MI, CVA

-decreased fertility for 3-12 months after

-actions decreased by antiseizure meds, antifungals, anti-TB, anti-HIV, antibiotics

-can be given in emergency w/in 72 hr

effects of the pill

-increased progesterone may stop menstruation and cause weight gain

-dangerous AEs: Abdominal (liver) pain, Chest pain (DVT→PE), Headache, Eye problems, Severe leg pain (DVT)

-at first increased estrogen causes nausea, breast tenderness, chloasma

-increased progesterone makes body think estrogen has dropped, causing early spotting, hypomenorrhea, vaginitis, painful sex

—also increased appetite, fatigue, depression, vaginal yeast infections, oily skin, hirsutism, amenorrhea

-low progesterone will cause heavy/irregular bleeding

other hormonal birth control

-patch (3 wks on, 1 wk off)

-vaginal ring

-IM progesterone q3mo (Depo-provera)

-implant (Nexplanon), lasts 2-3 years

IUD

-copper (spermicide, lasts 10 years) or Mirena (progesterone, lasts 5 years)

—also thins endometrium

-may cause PID, uterine perforation, ectopic pregnancy, vaginosis

-string stays behind cervix

-may be inserted right after birth or in emergency (w/in 5 days)

sterilization

-female = tubal ligation = occlusion

—reconstruction sometimes possible, but considered permanent

—Medicaid requires consent to be signed 30 days before procedure

-male = vasectomy

induced abortion

-need ultrasound and Rh Ig before

-defined as pregnancy ending before 20 weeks

-elective = pt request

-therapeutic = b/c of maternal/fetal health

-1st trimester = surgical (aspiration)

—local anesthesia

—suction cannula used

—heavy period-like bleeding after

-abnormal S/S: fever, chills, excess bleeding, smelly discharge, abdominal pain

-meds used 1st or 2nd trimester

—mifepristone blocks progesterone

—misoprostol stimulates contraction

—methotrexate

-2nd trimester = D&E or D&C, or induced delivery

—very risky

chromosomal abnormalities

-may lead to miscarriage, congenital issue, or gynecologic disorder

-occurs during meiosis or mitosis

-autosomal = of a chromosome number

genetic disorders

-usually multifactorial (e.g. cleft palate, congenital heart disease, neural tube defects, pyloric stenosis)

-risk

—occurrence = known to be at risk for having kids w/ disease

—recurrence = once child w/ disease has been born

-maternal & fetal blood never actually mix; nutrient transfer via chorionic villi

prenatal stages of development

(fertilization)→

zygote→

morula→

blastocyst→

(implantation)→

embryo→

fetus

prenatal layers

-endoderm becomes GI, liver, pancreas, inner lung

-mesoderm becomes CVS, epithelial lung tissue, skeleton, muscles

-ectoderm becomes hair, nails, skin, CNS

conception

-meiosis produces ovum & sperm

-estrogen increases uterine tube movement so cilia propel ovum

—fertile for 24 hours

—2 layers: inner = zona pellucida; outer = corona radiata

-hundreds of millions of sperm per mL (3.5 mL each time)

—average of 4-6 hours to reach tubes

—viable inside female for 2-3 days

—enzymes break down coating of ovum

fertilization

-in ampulla of tube (outer third)

-afterwards, membrane becomes impermeable to more sperm (zonal reaction)

-chromosomes & nuclei combin

-mitosis starts in 30 hours, blastocyst forms

-zygote stays in tube for 24 hrs; propelled to uterus w/in 3-4 days

-blastomeres form morula (16 cells in 3 days)

-forms trophoblast (future placenta) & embryoblast (→ blastocyst w/ cavity)

implantation

-on day 6-10

-may have bleeding at time of first missed period

-chorionic villi develop (vascular processes to transfer nutrients/waste between mom & baby)

-endometrium becomes decidua basalis

hormones during pregnancy

-progesterone maintains endometrium, decreases contractility of uterus, stimulates maternal metabolism, develops breast alveoli

-estrogen stimulates uterine growth & blood flow, proliferated breast glands, stimulates myometrial contractility

stages of pregnancy

-lasts from LMP to birth

-fetus is technically 38 weeks old at birth

-stages

1) ovum/pre-embryonic: till day 14

2) embryo: day 15 to 8 weeks

*most vulnerable to teratogens

3) fetus: 9 weeks to birth

*viability at 22-25 weeks, weight 350-500 g

fetal membranes

chorionic (by placenta) & amnion (by fetus)

amniotic fluid

functions:

-maintains temperature

-nourishes fetus

-teaches fetus to swallow

-takes waste & urine

-allows movement

-prevents cord wrapping

should be between 300 mL and 2 L

fetus breathes it in & out towards the end

yolk sac

-transfers nutrients till placenta can

-becomes primitive GI system till wk 5-6

umbilical cord

-develops week 14

-2 arteries & 1 vein, Wharton’s jelly surrounds & protects

-may wrap around neck = nuchal cord

-inserts on placenta:

—centric

—eccentric

—battledore/margin (edge)

—velamentous (membrane) (dangerous, may cause bleeding)

placenta

-Duncan side by mom, Schultz by baby

-chorionic villi forms 3 layers & divides into cotyledons; complete by 12 weeks

-circulation established by day 17 (heartbeat)

-metabolic exchange/storage

placenta functions

endocrine

-makes hCG (preserves corpus luteum to ensure E&P)

—peaks day 60-70, drops 100-130 days

-makes hCS/hPL (like GH)

—increases insulin resistance in mom to increase free glucose for baby

—transports glucose

—stimulates breast development

-makes E&P

circulation

-stores blood during contractions

-*mom cannot lay on back (blocks blood return and causes hTN

-*excess exercise & Braxton Hicks may block blood

fetal CVS

-blood starts forming wk 3, heart beats

-heart complete by 9 weeks

-special circle bypasses lungs (ductus arteriosus)

-Hgb carries 20-30% more O2 & is 50% more concentrated

-HR = 110-160 BPM

-hematopoeisis starts in yolk sac week 3; in liver week 6

-RBCs live 90 days

fetal GI

-upper forms week 5-6

-fetus swallows starting 5 mo or 20 wk

-produces meconium that is passed after birth

—passed before d/t stress; concerned about inhaling

-mature by 36 weeks

hepatic/renal fetal development

-bile at 12 wks

-glycogen storage wk 9-10

-lacking certain coagulation factors

—d/t no vitamin K synthesis (no normal flora)

-less gluconyl transferase enzyme (breaks down bilirubin)

-renal function at 9 weeks

—urine volume depends on renal function (decreased function will lead to oligohydramnios)

—GFR is low

fetal neural development

-neural tube at 4 weeks

-3 folds → forebrain, midbrain, hindbrain

-nerves at 8 weeks

-sound response at 24 weeks

-response to light at 24-26 weeks

-taste at 16 weeks

order of fetal circulation

-placenta vein is high pressure and O2-rich (goes from mom to baby)

-bypasses liver mostly (ductus venosus)

-inferior vena cava

-blood moves between atrium via foramen ovale

-bypasses lungs mostly (via ductus arteriosus)

-descending aorta → placenta via 2 arteries (low pressure, low-O2)

fetal endocrine development

-fetus makes own thyroxine at 8 weeks

-adrenals at 6 weeks, cortisol increases closer to term

-insulin at week 20 (does not cross placenta)

—mom w/ DM → fetal hypoglycemia → pancreas islet cell hyperplasia → macrosomia, neonatal hypoglycemia (they make insulin but aren’t getting glucose from placenta)

—also, fetal hyperglycemia → insulin spike → immature lungs

fetal reproductive development

-gender characteristics at week 9-12

-testes descend at week 28

-oogenesis at week 16

fetal musculoskeletal development

-by week 4

-skull sutures still have CT

—2+ bones meet = fontanel (anterior = diamond, posterior = triangle)

-movement by week 11-12

—perceived by mom week 16-20

fetal integument development

-epidermis at week 4

—1 layer mixes with sebaceous gland secretions to make vernix caseosa for protection

-lanugo at week 12-20

fetal immune development

-IgG crosses placenta

-fetus makes IgM by end of 1st trimester

-IgA from breastmilk

twins

-dizygotic

—increased FSH→multiple ova released→2 fertilized

—fraternal

-monozygotic

—1 fertilized ovum divides after 4-8 days

—shared placenta

—earlier split→more shared materials→higher danger

—“identical”

—monochorionic & monoamniotic twins will need to be induced early

Depo-provera

-synthetic progesterone

-converts proliferative phase to secretory, inhibits FSH & LH

-150 mg IM q3mo

-AEs: depression, fluid retention, fatigue, dizziness, nausea, anorexia, jaundice

-teach: report ACHES S/S, vomiting, dizziness, etc

Nexplanon

-implantable

-progestin

-works for 3 years

-minor surgical procedure requiring local anesthesia

-AEs: irregular menstruation, HA, nervousness, skin changes, vertigo

drospirenone/estetrol

-synthetic progestin

-also used for acne & PMDD

-prevents fluid retention

-higher risk of blood clots

-check K+ levels before

diuretics during pregnancy

-not usually used

-may be needed for kidney failure, liver failure, or HTN

-may cause F&E imbalance

-if used: check I&O, daily weight

-give early in the day