OB exam 1 (day 1)

what age does menarche (period) begin?

approximately 13 years of age.

The average duration of menstrual flow and amount loss

5 days and the average blood loss is 50 mL

phases of Endometrial Cycle 

• Menstrual phase 

• Proliferative phase

• Secretory phase

• ischemic phase

menstrual phase

• Day one of the cycle (important so we can calculate moms due date).  

• Estrogen is low

proliferative phase

• 5th day of the cycle to the time of ovulation.   

• Vascularity of the uterus increases, and the endometrium becomes prepared for a fertilized ovum (proliferates).  

• Estrogen peaks just prior to ovulation because it is secreted by the ovaries and is crucial for the development and maturation of the follicle.  

secretory phase

• Day of ovulation (day 14 of cycle) to approximately 3 days before the next menstrual period.  

• Secretes small qualities of endometrial fluid in preparation for a fertilized ovum.  

• Endometrium reaches the thickness of heavy, soft velvet.  

• Estrogen drops sharply and progesterone dominates because it is secreted by the corpus luteum

Corpus luteum 

• A small yellow body that develops within a ruptured ovarian follicle.  

• Supplies most of the estrogen and progesterone in the first two gestational months before the placenta is fully developed at 8 weeks

• Placenta will then secrete hormones when it’s developed

ischemic phase

• Days 27-28 (last 2 days).  

• If fertilization does not occur, the ischemic phase begins.  

• Blood supply to the endometrium is reduced.  

• The corpus luteum begins to degenerate bc she’s not pregnant, and as a result both estrogen and progesterone levels drop. 

Hypothalamic-pituitary cycle 

• At puberty, the hypothalamus synthesizes and releases GnRh (a hormone that stimulates the gonads-ovaries or the testes).  

• GnRh is transmitted to the anterior pituitary, where it causes the synthesis and secretion of the gonadotropins: FSH (stimulates the follicle or ovum sac to mature) and LH (stimulates the release of the ovum from the ovary). 

• Ovaries increase secretion of estrogen and progesterone.  

phases of ovulation cycle

• folicular

• luteal

Ovarian Cycle  

• Before ovulation (day 14), follicles begin to mature in each ovary under the influence of FSH and estrogen.  

• The preovulatory surge of LH affects a selected follicle.  

Ovarian Cycle: folicular phase

• Varies in length from woman to woman and accounts for almost all variations in ovarian cycle length

• this is why some months your period comes a few days early or late; starts at menstruation and ends at ovulation).

Ovarian Cycle: luteal phase

• Begins immediately after ovulation and ends with the start of menstruation. 

• If no implantation occurs, the corpus luteum regresses, steroid levels drop, and menstruation occurs. 

why should all new moms know how to do Kegel Exercises?

bc they’re at risk for stress incontinence (pee while sneezing)

kegel exercises

• Technique used to strengthen the muscles that support the pelvic floor. 

• Teach the woman to pretend that she is trying to prevent the passage of intestinal gas. Have her use this tightening motion on the muscles around her vagina and the upper pelvis. 

• Another suggestion is to have the woman pretend she is trying to stop the flow of urine in midstream. 

• Contractions should be held for at least 10 seconds. 

implications of UTIs and STIs during pregnancy

Uti and STI can cause preterm labor so we always do STI tests on mom when baby is born preterm 

bacterial STIs

• Chlamydia

• Gonorrhea

• Syphilis

Chlamydia

• Most common and fastest-spreading STI  

• Infections often silent and highly destructive  

• Difficult to diagnose bc woman usually presents w no s/s 

what can chlamydia result in

Pelvic Inflammatory Disease (needs abx)

what are Past chlamydial infections associated with?

increased risk of ectopic pregnancy (plants into fallopian tube= can result in infertility) and tubal factor infertility. 

tubal factor infertility

damage, scarring, or blockages in the fallopian tubes prevent sperm from reaching an egg or stop a fertilized egg from traveling to the uterus

screening and dx of chlamydia

• Screening is done on asymptomatic and pregnant women  

• dx: Culture 

s/s of chlamydia

 Although infection is usually asymptomatic, some women may experience

• spotting or postcoital bleeding

• mucoid or purulent cervical discharge

• dysuria

tx of chlamydia

• If the woman is pregnant, azithromycin (if they have health insurance) (single dose) or amoxicillin (if they don’t have insurance) is used.  

• All exposed sexual partners should be treated within 30 days. 

what happens is chlamydia goes untreated

newborn can be born with pneumonia and conjunctivitis

• can turn into ophthalmia neonatorum and can go blind so all babies get erythromycin at birth

bacteria that causes gonorrhea

Neisseria gonorrhoeae 

transmission of gonorrhea

• Main way: genital-to-genital contact; however, it is also spread by oral-to-genital and anal-to-genital contact.  

• Transmitted through Mother to newborn  

• can also be transmitted to the newborn in the form of ophthalmia neonatorum during birth by direct contact with gonococcal organisms in the cervix. 

age group most at risk for gonorrhea

20-24 years old

s/s of gonorrhea

• Women are often asymptomatic  

• But when they are symptomatic, they may have a greenish-yellow purulent endocervical discharge or may experience menstrual irregularities.  

• Pelvic or abdominal pain (signs of PID) 

• Rectal complications (usually if they got it thru anal sex)

Screening and Diagnosis of gonorrhea

Thayer-Martin Culture

• red culture dish

• swab the cervix then the culture

tx of gonorrhea

• Ceftriaxone 500 mg single dose IM.   

• treatment for chlamydia if this infection is not ruled out bc they usually present together.  

• Recent (previous 30 days) sexual partners should be examined, cultured, and treated with appropriate regimens. 

Legal tip: Reporting a communicable disease  

• Syphilis, gonorrhea, chlamydia, chancroid (ulcers of perineum), HIV and AIDS are reported disease in every state

• Health care providers are legally responsible for reporting all cases to the health authorities, usually the local health department in the woman’s county of residence

• Inform women that the case will be reported, told why, and informed of the possibility of being contacted by the health department epidemiologist.  

bacteria that causes syphilis

Treponema pallidum 

transmission of syphilis

• Transmission by entry in 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 

  • mother to child but before the baby is born

what can syphilis lead to

serious systemic disease and even death

primary syphilis

chancre sore

Secondary syphilis (s/s)

If primary is not tx they progress to this

• Maculopapular rash on the palms and soles of feet and generalized lymphadenopathy

• The infected individual also may experience fever, headache, and malaise. 

Tertiary syphilis (s/s)

If secondary is not tx they progress to this

• Neurologic and cardiovascular, and musculoskeletal or multiorgan system complications can develop

who gets screened for syphilis

pregnant women

dx of syphilis

• Serologic tests done of first prenatal visit (blood test) 

• Types: VDRL (venereal disease research lab) or Rapid Plasma Reagin. . 

• No syphilis= negative or nonreactive 

• Syphilis= positive or reactive 

false positives with syphilis

False-positive results are not unusual, particularly when conditions such as acute infection, autoimmune disorders, malignancy, pregnancy, and substance use disorder exist and after immunization or vaccination 

tx of syphilis

• PCN G IM

• Women who have a history of allergy to penicillin should be desensitized and treated with penicillin

  • give them small doses and build them up until they become immune to reaction

 

viral STIs

• Human Papillomavirus (HPV)

• Genital Herpes Simplex Virus

• HIV

virus that causes Human Papillomavirus (HPV)

Condylomata acuminata

Human Papillomavirus (HPV)

Most prevalent viral STI seen in ambulatory health care settings

what does HPV cause and education

• the primary cause of cervical neoplasia (cervical cancer) 

  • education: Needs regular pap smears (once a year) 

s/s of HPV

• Vaginal lesions are often multiple.  

• Flat-topped papules, 1 to 4 mm in diameter, occur most often on the cervix

screening and dx in HPV

• History of known exposure 

• Physical inspection 

• Pap smear 

•  The only definitive diagnostic test for presence of HPV is histologic evaluation of a biopsy specimen (best way) 

care management of HPV

• No therapy has been show to eradicate it bc it’s permanent

• Removal of the warts may be considered; however, it is recommended to wait until the pregnancy has ended.  

• we usually tx symptoms

ways to tx symptoms in HPV

• Bathing with an oatmeal solution

• drying the area with a hair dryer on a cool or low setting

• cotton underwear

• loose-fitting clothes

• Diet, rest, stress reduction, and exercise.  

types and transmission of Herpes Simplex Virus 

• Herpes simplex virus 1 (HSV-1) 

  • Transmitted nonsexually (kissing) 

• Herpes simplex virus 2 (HSV-2) 

  • Transmitted sexually 

s/s of genital Herpes Simplex Virus  

• Pruritus and paresthesia (tingling)

• redness of the genital area are prodromal symptoms of recurrent herpes infection 

screening and dx of HSV

suspected from the history and physical examination

• confirmed by viral tissue cultures. 

tx of HSV

• Acyclovir and valacyclovir is safe during pregnancy

• there is no published data on famcicloviruse during pregnancy, and therefore it is not use.  

• management: Wear loose cotton underwear

• if mom has active lesions, she CANNOT have a vaginal birth

what happens if mom does give birth vaginally with active lesions

• baby will have herpes all over body

• thats why if mom tells u they have herpes, first thing you do is examine genital area  

transmission of Human Immunodeficiency Virus (HIV)  

• Transmission of HIV occurs primarily through exchange of body fluids (semen and blood) 

• Seroconversion in 6 to 12 weeks (aka how long it will take symptoms to show up after exposure) 

screening for HIV in pregnancy

• All moms are screened for HIV  as early as possible in pregnancy and a second test in the third trimester

  • especially important for women known to be at high risk for HIV infection. 

if HIV screening is positive…

Perinatal transmission has decreased due to antiretroviral therapy (ART)

• reduces chance for baby to get it

antiretroviral therapy (ART) for HIV

• Administered orally and continued throughout pregnancy 

• Treatment of HIV-infected women with ART during pregnancy has been reported to decrease the mother-to-child transmission to less than 2% 

• ART is administered IV 3 hours before the scheduled cesarean birth and is continued until the baby is born

• It should be given during labor and birth if the woman is having a vaginal birth. 

• ART prophylaxis should be started orally preferably within 12 hours of life. The newborn is usually treated for 6 weeks (p. 781)***

considerations with ART therapy for HIV

• Major side effect is bone marrow suppression 

• Periodic HCT, WBC count, and PLT count assessments should be performed 

c section vs vaginal birth with HIV

dependent on the degree of viral load

breastfeeding w HIV

• Breastfeeding is not recommended in the United States and most developed countries bc virus is in breastmilk

• however, underdeveloped countries do allow breastfeeding (Africa) bc of no access to formula 

vaginal infections

• bacterial vaginosis (not an STI)

• candidiasis (yeast infection)

• Trichomoniasis (STI) 

bacterial vaginosis

• Most common type of vaginitis 

• Associated with preterm labor and birth 

s/s and dx of bacterial vaginosis

• *Woman reports of fishy odor and increased thin vaginal discharge are most significant.  

• dx: The fishy odor of BV will be released when KOH is added to vaginal secretions on the lip of the withdrawn speculum. 

tx of Bacterial vaginosis

• oral metronidazole (Flagyl) is most effective.  

• In the past, women were counseled to not consume alcohol while taking metronidazole, but the CDC found not data to support this practice and it was removed from their 2021 STI Treatment guidelines.  

• partner tx is not needed bc its not an STI

candidiasis and organism

• Vulvovaginal candidiasis, or yeast infection, is second most common type of vaginal infection 

• Most common organism is Candida albicans 

Factors affecting predisposal of candidiasis

• Antibiotic therapy 

• Diabetes 

• Pregnancy 

• Obesity 

• Diets high in refined sugars 

• Use of Corticosteroids 

• Immunosuppressed states 

common symptoms of candidiasis

• Vulvar and vaginal pruritus (itching) 

• White discharge 

  • If baby gets it in mouth during birth, they’ll have thrush 

screening and dx of candidiasis

• Physical examination 

• Vaginal pH 

• Saline and KOH wet smear and vaginal ph. 

•  Vaginal pH is normal (less than 4.5) with a yeast infection

tx and comfort management in candidiasis

• tx: OTC Miconazole (Monistat)  

• management

  • Sitz baths  

  • Adding colloidal oatmeal powder to the bath  

  • Not wearing underpants to bed may help decrease symptoms and prevent recurrences. 

Trichomoniasis (STI) 

• Trichomonas vaginalis   

• an STI

• Common cause of vaginal infection 

transmission of trichomoniasis

sexually transmitted

s/s of trichomoniasis

may be asymptomatic, but women commonly experience:

• characteristically yellowish to greenish, frothy, mucopurulent, copious, malodorous discharge

screening and diagnosis of trichomoniasis

• Speculum examination 

• Pap smear 

• Reliable samples for testing are clinician-collected endocervical swabs, clinician-collected vaginal swabs, urine samples, and liquid Pap specimens collected in PreservCyt Solution

tx of trichomoniasis

Metronidazole orally twice per day for 7 days 

• Although the male partner is usually asymptomatic, he should receive treatment also because men often harbors the trichomonads in the urethra or prostate. 

TORCH Infections  

• Toxoplasmosis 

• other infections

• Rubella

• Cytomegalovirus 

• Herpes simplex 

TORCH: toxoplasmosis prevention

• Good handwashing 

• Avoid raw or rare meat and exposure to cat litter

  • ask if mom has a cat, if yes, she CANNOT handle their feces

• If she gardens, she MUST wash her hands and wear gloves 

adverse affects of toxoplasmosis

• Fetal injury is greatest when maternal infection occurs during the first trimester. 

• Baby can be born w birth defects 

TORCH: other infections

• Hepatitis A 

• Hepatitis B 

TORCH: Rubella

• screen on mom’s first visit

• Approximately 50%-80% of fetuses exposed to the virus within 12 weeks after conception will show signs of congenital infection.  

• Vaccine is only given post-partum even if they’ve just been exposed bc it can cause birth defects  

TORCH: Cytomegalovirus 

• The fetus can be infected transplacentally.  

• The virus is transmitted by infected organ transplant, blood, sex, saliva, or urine.  

• Causes congenital infections

• Wash hands after handling infant toys and diapers.  

  • Daycare workers are at risk 

  • Wear gloves when changing baby diapers, wash hands, and clean babies toys 

TORCH: herpes simplex

Risk of transmission is greatest during vaginal birth if woman has active lesions; thus cesarean birth is recommended. 

Fertility Awareness-Based (FAB) Methods 

• Calendar rhythm method  

• Cervical mucus ovulation-detection method  

• Basal body temperature (BBT) method

affectiveness of Fertility Awareness-Based (FAB) Methods 

• FAB methods have decreased effectiveness in women with irregular cycles (particularly adolescents and menopause who have not established regular ovulatory patterns). 

• NFP methods are the only contraceptive practices acceptable to the Roman Catholic Church. 

NFP methods (non-family planning)

daily observation of biological signs—such as cervical mucus, basal body temperature, and hormone levels—to track a woman's fertile window and either achieve or avoid pregnancy

Calendar rhythm method

• The human ovum can be fertilized no later than 12 to 24 hours after ovulation. 

• The sperm’s ability to fertilize the ovum probably lasts no longer than 24 to 48 hours. 

• If the woman has a very regular cycle of 28 days, pregnancy is unlikely to occur if a couple abstains from intercourse for 4 days before and for 3 or 4 days after ovulation. 

• Practice of the calendar rhythm method is based on the number of days in each cycle counting from the first day of menses.  

considerations for Calendar rhythm method

• With this method, the woman determines the fertile period after accurately recording the lengths of menstrual cycles for 6 months

  • only do after monitoring period for 6 months 

Cervical mucus ovulation-detection method  

• The cervical mucus ovulation-detection method (also called the Billings method) requires that the woman recognize and interpret the cyclic changes in the amount and consistency of cervical mucus that characterize her own unique pattern of change.  

• Women check the quantity and character of mucus on the vulva or introitus with fingers or tissue paper each day for several months to learn the cycle.  

• Intercourse is considered safe without restriction beginning 4 days after the last day of wet, clear, slippery mucus (post ovulation).  

Cervical mucus ovulation-detection method: ovulation mucus

• Ovulation mucus: clear, wet, sticky, slippery 

• It feels similar to a lubricant and can be stretched 5+ cm between the thumb and forefinger; this quality of mucus is called spinnbarkeit

  • don’t have sex for next 4 days if you see spinnbarkeit

Basal body temperature (BBT) method

• Mittelschmerz

• May see a slight drop in temperature about the time of ovulation. 

• Temperature will rise (at least 0.2° C) around the time of ovulation and stay elevated until just before the next menses (increases bc of progesterone).

Basal body temperature (BBT) method: Mittelschmerz

some women can feel a twinge (ovum released from ovary) when they ovulate

how to measure Basal body temperature (BBT)

• Take BBT using a special calibrated thermometer every morning at the same time before you get out of bed. 

• Record temperature daily on a graph and connect the dots.  

considerations with Basal body temperature (BBT)

Avoid intercourse until 3 days of higher temperatures occur.  

things that can affect temp when doing the Basal body temperature (BBT)

• Infection

• fatigue

• less than 3 hours sleep per night

• awakening late

• anxiety (stress)

• Jet lag

• alcohol taken the evening before

• sleeping in a heated waterbed

barrier methods

• condoms

• diaphragms

• cervical caps

considerations with condoms

• Condoms lubricated with N-9 are not recommended for preventing STIs or HIV.  

• Latex condoms will break down with oil-based lubricants and should be used only with water-based or silicone lubricants (KY jelly).  

• Spermicide-coated condoms cause ejaculated sperm to be immobilized rapidly, thus increasing contraceptive effectiveness. 

• Failure rate: 13%.  

safety alert with condoms

• contraindicated with latex sensitivity.  

• Store unused condoms in a cool, dry place.  

  • Not in wallet or glove compartment 

diaphragms

• A shallow, dome-shaped latex or silicone device with a flexible rim that covers the cervix.  

• Need to be fitted by HCP and it will need to be refitted for a 20% weight fluctuation, after any abdominal or pelvic surgery, and after every term pregnancy. 

SE of diaphragms

irritation of tissues related to contact with spermicides