Simmons 501 Women's Health Exam 2 MASTERY GUIDE: 88 Expert-Verified Q&A on Pregnancy, Complications & Postpartum Care (NCLEX-Aligned with 100% accurate rationales )

Presumptive signs of pregnancy

N/V (morning sickness), breast tenderness, quickening, amenorrhea, excessive fatigue

Probable signs of pregnancy

Goodell sign: softening of cervix

Chadwick sign:cervix is blue/purple

Hegar's sign: softening of lower uterine segment (4th mo pregnancy)

Positive pregnancy test

braxton-hicks contractions

Diagnostic for pregnancy

Fetal heart tones (doppler, US, fetoscope), see baby kicking/moving after 20 weeks

Pathophysiology of Symptoms of Pregnancy

Yeast infections: vaginal pH increases, more susceptible

Constipation: slowed peristalsis, displacement of intestines, increased progesterone can result in decreased intestinal contractiltiy

Swollen gum: hypertrophy of the gums due to decreased vascular resistance and increased in growth of capillaries

Respiratory congestion: blood vessels in nose vasodilate can also result in bloody nose.

SOB: fetal growth --> pressure on diaphragm

GERD: displacement of abd organs and altered esophageal sphincter and gastric tone r/t increased progesterone levels

Gallstones: predisposed to gallstone formation related to sluggish emptying of bile from the gallbladder combined wtih increased cholesterol satuation during pregnancy

ligament pain: progesterone and relaxin soften ligaments and muscles

UTI: renal tubules dilate--> urinary stasis --> increased risk UTI.

Urinary frequency: progesterone decreases bladder tone which can lead to frequency and incontinence

When is Urine pregnancy test usually positive?

14 days post fertilization

which is 4 weeks after LMP

If period is a few days late

When does HCG blood serum show up?

can detect presence of hCG 8-10 days after fertilization

repeated quantitative hCG tests are useful in determining the viability of a pregnancy from implantation until 9 weeks, when hCG begins a physiologic decline

Quickening

happens 16-20 weeks

this is when mom feels the fetal movements

if mom doesnt feel baby move for more than 6-8 hours she should call the office

Fetal Heart Tones detected when?

Doppler at 10-12 weeks

visible cardiac activity on US as early as 6-8 weeks

fetoscope at 17-20 weeks

Nagele's Rule

LMP + 7 days - 3 months = EDD

If patient doesn't know LMP use US to estimate date using crown to rump measurement

Anemia of pregnancy

b/c blood volume increases significantly (more plasma than RBCs) we can see anemia in pregnancy

Concerned with Hgb of 11 or lower

- start iron supplements

GTPAL for history of pregnancy documentation

Gravida: number of times pregnant (including current)

Term: number of term pregnancies (37+ weeks)

Preterm: number of living children 20-36 weeks

Abortion: spontaneous or induced abortions prior to 20 weeks

L: living children

Cardiac Changes in Pregnancy

Cardiac Output increases 30-50%

HR increases by 15-20 beats by 32 weeks gestation

increased risk of clotting b/c increased clotting factors

Volume of S1 may be increased with splitting, S3 can be detected.

CONCERNING: murmurs graded 3 or 4 or other symptoms like SOB with murmur --> send for cardiac workup

Thyroid in pregnancy

Thyroid may be enlarged

if it is still symmetrical and no symptoms not a huge cause for concern

Kidneys in pregnancy

kidneys are displaced and increase in size in pregnancy

renal tubules dialte --> urinary stasis which increases risk of UTI

bladder tone decreased due to effects of progesterone which can lead to urinary frequency and incontinence

***frequency more common in first and third trimesters

Skin changes in pregnancy

Linea nigra (dark line from sternal notch to symphysis pubis and genitalia

nipples and areola darken

chloasma gravidium (pregnancy mask)

Uterine height by weeks

12 weeks: fundus at symphysis publis

16 weeks: halfway between symphysis pubis and umbilicus

20 weeks: umbilicus

36 weeks: xyphoid process

40 weeks: moves lower than xyphoid b/c of engagment

until term fundus enlarges approximately 1 cm per week

Vaginal discharge in pregnancy

Leukorrhea is normal: think or thick white or yellow discharge w/out itching or irritation, most common during second trimester

extra mucus/vaginal discharge is normal

Vaginal pH increases making pregnant women at increased risk for candidiasis

Risk factors for genetic anomalies

Maternal age >35

high-risk racial/ethinic groups

- tay sachs: ashkenazi jews

- cystic fibrosis - caucasians

- sickle cell- african descent

mother and father related by blood

geneteic conditions

congenital malformations

congenital blindness/deafness

stature disorders (very tall/short)

developmental delays/mental retardation

maternal exposure to toxins

unexplained maternal/paternal infertility

FIrst Prenatal Visit: Tests and interventions

urine test with culture

test for gonorrhea, chlamydia, syphilis, hep B, HIV

CBC

rubella titer

blood type and RH factor

DO NOT ROUTINELY test for toxoplasmosis, only test those at risk

DONT routinely screen for Varicella

- screen those with no history of natural infection (bigger group now b/c of vaccinations)

start prenatal vitamins

figure out EDD

document using GTPAL

screen for intimate partner violence (first visit and every trimester)

Weight gain based on BMI

BMI < 18.5 (underweight): 28-40 lbs

BMI 18.5-24.9 (normal): 25-35 lbs

BMI 25 to 29.9 (Overweight): 15-25 lbs

BMI 30+ (Obese): 11-20 lbs

Risk factors for Intimate partner violence

Pregnancy

substance abuse

history of depression

low self esteem

younger age (college age especially)

raised in a violent family

history of violence

lower educational level

poverty, unemployed

vaccinations in pregnancy

Recommended in each pregnancy:

- TDap: 27-36 weeks in each pregnancy to prevent pertussis, infants are at increased risk and dependent on passive immunity until first vaccine at 2 mos

- Flu shot (not mist)

if at risk for acquiring HBV may start hep B vaccinations

NO LIVE VACCINES! No rubella, no varicella, no yellow fever

Prenatal visit frequency

q4weeks for uncomplicated pregnancy until 28 weeks, then q2 weeks from 28-36 weeks, then weekly 36 weeks to delivery

Nausea + pregnancy

N/V typically begins before 9 weeks, peaks at 12 weeks and subsides by 20 weeks

ensure patient is able to stay hydrated

lessening symptoms:

- 5-6 small meals per day

- blank, lukewarm or cold foods

- protein or carbs 45 min before rising

- if iron multivitamin exacerbates nausea may take folic acid only (400 mcg) till symptoms resolve

- acupressure bands

- ginger (maximum daily dose 1000 mg)

Fatigue in pregnancy

peaks around 9-12 weeks

differential diagnosis: hypothyroid, anemia, cardiac issue

Hyperemesis Gravidarum

severe/persistent N/V in pregnancy

signs of dehydration: weight loss, ketones in urine

only FDA approved pharmacological tx is Diclegis

* diagnose hyperemesis instead of morning sickness when signs of dehydration are present

Testing during pregnancy

Maternal serum screening: 10-14 weeks

nuchal translucency: 10-14 weeks

AFP, quad screen: 15-22 weeks

Anatomy US: 18+ weeks gestation

Glucose Tolerance Test: 24-28 weeks

Rhogam if Rh- : 28 weeks

GBS: 35-37 weeks

quad screen: common test for trisomy and neural tube defects

Quad Screening

done 15-22 weeks

tests levels of AFP, hCG, estriol and inhibin A

detects increased risk for neural tube defects, trisomies 13,18 ans 21

Anatomy US

done 18+ weeks

looks at umbilical cord, placenta, fetal structure abnormalities, amniotic fluid

good second test if quad screening comes back abnormal.

This is the test to look at amniotic fluid levels!

non-invasine prenatal testing

Done at 10 + weeks

not for everyone, used in high risk patients

examination of cell-free fetal DNA within maternal blood

screenings for aneuploidy, trisomies 13, 18, 21. it is not diagnostic but slightly more accurate than quad screening

if screening tests are positive then refer for diagnostic test before making diagnosis

Screening tests vs Diagnostic

Screening tests ARE NOT DIAGNOSTIC. Indicates increased risk. Further testing is needed for a diagnosis

diagnostic tests are things like: amniocentesis or chorionic villus sampling (these have risks like bleeding, miscarriage, infection, ROM)

Five P's of Sexual Health

Partners

Prevention of pregnancy

Protection from STDs

Practices

Past history of STDs

Spontaneous abortion Management

as long as there is no heavy bleeding, most often expectant management is done

monitor weekly till hCG is zero.

if incomplete SAB then D&C is warranted

implantation bleeding

bleeding that is normal in pregnancy, occurs usually around the time of missed period

not heavy bleeding, usually spotting

Ectopic Pregnancy

Classic signs: pain, bleeding, + pregnancy test.

S/Sx: CVA tenderness, unilateral pain, adnexal mass, uterus smaller than expected for dates.

hcg levels rise more slowly than expected

US to diagnose. CBC, hCG

Send for emergency treatment! This is an emergency, can lead to bursting of tubes, hemmorhage and death.

Hydatiform mole

Classic: severe hyperemesis, severe nausea, bleeding, hCG levels higher than expected, dark red/brown bleeding

see: mass of grape-like structures or "snow storm" on US

concern for potential malignancy.

f/u:

- serial hCG weekly till zero, follow for 3 weeks in a row till they star at zero.

- f/u monthly for 6-12 months

- no pregnancy for 6-12 months following molar pregnancy

risk factors: age 40+, previous hx molar pregnancy, hx infertility, smoking

Chlamydia during pregnancy

tx: 1 gram azithromycin PO once (same as nonpregnant but avoid docycycline)

difference in pregnancy is test of cure:

test at 3-4 weeks and again at 6 months

*infection in pregnancy can cause SAB and preterm labor

UTI in pregnancy:

asymptomatic bacteriuria is common

Most common: E.Coli, Group B strep

infection puts women at risk for preterm labor so we treat even if asymptomatic

USually treat with:

- penicillins, cephalosporins, aztreonam and fosfomycin (uptodate)

- avoid nitrofurantoin (macrobid) in the first trimester (uptodate)

Avoid BACTRIM!!!! sulfa aspect causes hyperbilirubinemia and should be avoided in the third trimester and trimethoprim is a folate antagonist that should be avoided during the first semester of pregnancy

We routinely screen for _____ during pregnancy

gonorrhea/chlamydia, syphilis, HIV, Hep B

We do not routinely screen for _____ during pregnancy

Toxoplasmosis and CMV

- screen only if high risk

Toxoplasmosis

usually asymptomatic in non-immune compromised mom

fetal effects include vision or hearing loss, neurologic delays and seizures

most concerning in first trimester

avoidance:

- proper cooking and handling of meat (esp pork)

- having someone else clean litter box

- using gloves if gardening

- thoroughly cleaning fruits and vegetables

GOOD HAND WASHING AND HYGIENE ARE BEST FORM OF PREVENTION

CMV

maternal symptoms are flu like symptoms although many may be asymptomatic

newborn infections associated with hepatosplenomegaly, thrombocytopenia, hepatitis and anemia

GOOD HAND WASHING AND HYGENIC PRACTICES ASSOCIATED WITH SHARED ITEMS (TOYS, HARD SURFACES) ARE BEST FORM OF PREVENTION

Herpes simplex + pregnancy

most concerning if outbreak is near delivery

active outbreak may require C section

acyclovir may be given to prevent outbreaks in the 3rd trimester

Preterm labor

labor between 20 and 36+6 weeks

s/sx: menstrual-like cramps, a dull backache, pelvic pressure prior to 36 weeks gestation, diarrhea, increased vaginal discharge, leakage of clear fluid from the vagina, vaginal bleeding

management: decreased physical and sexual activity (pelvic rest), increased fluid intake, avoid breast stimulation

Glucose Testing in Pregnancy

done 24-28 weeks (earlier if certain risk factors)

50 grams 1 hour GTT initially: >200 is GD, >130-140 they do 100 gram GTT: 2 abnormal levels mean GD

fasting: >95 mg/dl

1 hour: >180 mg/dl

2 hour: >155 mg/dl

3 hour: > 140 mg/dl

gestational HTN

over 140/90 after 20 weeks gestation !!

it isnt pre-eclampsia if there is no proteinurea or preeclampsia symptoms (edema, headache)

Pre-eclampsia

HTN (>140/90) + proteinurea (twice more than 4 hours apart)

HTN and thrombocytopenia, renal insufficiency, impaired liver fx, pulm edema, cerebral or visual changes.

Complications: eclampsia and HELLP

HELLP

HTN, Elevated liver enzymes, Low platelets

severe epigastric pain and headache/vision changes would be suspicious

RUQ pain could be liver rupture

refer or do blood work to r/o HELLP, HELLP Can be life threatening

Eclampsia

tonic-clonic seizures, life threatening emergency.

must delivery baby if there is eclampsia

Placenta Previa

placenta implanted too low (over cervical os)

S/sx: painless, bright red bleeding late in pregnancy

pg 815: complete previa, partial previa, marginal previa, low lying previa

complete and partial: must deliver via C section

marginal or low lying may not need C section

Abruptio placenta

occurs when placenta separates from the uterine wall

S/sx: painful bleeding, dark red bleeding, sudden sharp abdominal pain, board-like abdomen

EMERGENCY! can cause fetal death, hemorrhage, maternal death

Contraception in post partum

LAM: valid if there is exclusive breastfeeding when child is under 6 months

no estrogens for 4- 6 weeks postpartum b/c of risk of DVT

progesterone is safe

IUDs must be inserted immediately postdelivery or wait until 4-6 weeks postpartum

uterine involution

involution begins immediately postpartum, descends at a rate of about 1 cm per day (day 1 at umbilicus)

by 10-14 days the uterus should be a pelvic organ (not palpable abdominally)

at 6-8 weeks the uterus has returned to its normal size

Lochia postpartum

Rubra: dark red. 2-5 days

Serosa: pale red 3-10 days

alba: white/yellow 10 days-6 weeks

it not itching and no odor the lochia discharge is normal

call provider if bleeding through more than 1 pad per hour

clots are common but should not be bigger than a golf ball, call if you see abnormal clotting

Breast engorgement vs mastitis

engorgement is common, especially if women aren't breastfeeding.

usually occurs 2-3 days postpartum and may show up with a low-grade fever. usually see bilateral breast pain/tenderness

mastitis: unilateral with localized erythema, breast tenderness, red streaks, warmth, fever, chills, severe pain.

occurs LATER than engorgement, usually several weeks-6 months after delivery

tx for mastitis is encourage frequent feeding, ensure proper latch and nipple integrity. Return if she starts having fever, increased pain, increased warmth

Baby blues vs depression vs psychosis

Baby blues:

- less than two weeks, usually early in PP period

- moodiness, sadness, tearful, no thoughts of harming baby

depression

- >2 weeks symptoms

- more impact on life (appetite changes, sleep disturbance, loss of interest in baby, thoughts of harming self or baby)

Psychosis

- hallucinations, delusions, paranoia, hyperactivity

- THESE WOMEN NEED IMMEDIATE CARE

Abortion

be sure to confirm pregnancy. Must get an accurate gestational age because abortions are safer earlier (esp before 13 weeks)

7-9 weeks:

- methotrexate+ misoprostol (90% effective)

- mifepristone + misoprostol (92-98% effective)

<15 weeks may do suction and curette

late abortion 15 weeks +

- must do D&C

BUBBLE-HE

Breast size, shape, engorgement

Uterus: firm or boggy, appropriate height

Bladder: tender or distended

Bowel movement?

Lochia: amount, color, odor, clots

Homan's sign: positive

Emotional Status and bonding

When to screen for GBS

35-37 weeks

Only FDA approved antiemetic in pregnancy

Diclegis (In israel Diclectin)

Absolute CI to Estrogen?

known or suspected CA of the breast

history of uterine/ovarian CA

Undiagnosed, abnormal genital bleeding

history of or active thromboembolic disorder

Absolute CI to progestin?

Active thrombophlebitis or thromboembolic disease

liver disease

known or suspected cancer of the breast

undiagnosed abnormal vaginal bleeding

Common SEs of Estrogen-progestogen Therapy

Bleeding and breast tenderness are most common

other include bloating, weight gain, nausea, mood changes

Common SEs of Estrogen therapy

Uterine bleeding, breast tenderness, nausea, bloating, fluid retention in extremities, headache, dizziness, hair loss

Types of Estrogen

Estradiol (E2): most potent form of estrogen, produced during reproductive years

Estriol (E3) secreted by placenta and synthesized from androgens produced by the fetus during pregnancy

Estrone (E1) is the weakest estrogen, primary estrogen present in postmenopausal women, children and men

Hormone Therapy

use lowest possible dose for shortest time

try to stop after 3-5 years (this is especially for EPT b/c increase risk of breast CA)

have women initiating HT come back after 6-8 weeks to follow up/discuss expectations

relief of vasomotor symptoms can take 2-6 weeks, SSRIs work more quickly

SMOKERS CAN USE HT, not a CI

transdermal patch for HT

lower risk of DVT b/c it is a lower dose, released more steadily

prevents first pass through liver which has a positive effect on the clotting issue

Treatment for VAGINAL symptoms of menopaise

if MAIN SYMPTOMS ARE VAGINAL then offer vaginal estrogen first

if using low dose vaginal estrogen and the woman has a uterus then you do not need to add progesterone

it is not absorbed systemically into the blood system, can be used long-term

SSRIs for Menopause symptoms

SSRIs work immediately to help hot flashes

Don't need to worry about withdrawal with lower doses.

Brisel is low-dose paroxetine marketed for menopause

Perimenopause symtpoms can last for:

2-8 years

ONLY FDA APPROVED RX therapy for hot flash treatment in women with history of or high risk of breast cancer

Paroxetine (SSRI)

menopause

defined as 12 consecutive months without a period

age range:40-58 y.o.

average age is 52

lab testing not required to diagnose menopause now. If in appropriate age range, having symptoms, skipping periods...can diagnose

Sx: vaginal dryness, skin dryness, hair dryness, hot flashes, night sweats, loss of sexual interest

FDA approved med for hypoactive sexual desire disorder

FDA approved: Flibanserin (serotonin receptor agonist)

wellbutrin (buproprion) is off-label for this.

refer for sex counseling

Sexual arousal/interest disorder diagnostic criteria

Need 3 or more:

1. absence /reduced interest in sex

2. absence/reduced fantasies and erotic thoughts

3. absent/decreased desire to initiate encouters with partner and usually unreceptive when partner attempts to initiate encounters

4. absent/reduced sense of pleasure during sex

5. absent/reduced response to sexual cues

6. absent/reduced sensations in genitals or elsewhere during sex

Physiologic Breast discharge

bilateral usually

comes from multiple ducts

is white, clear, yellow, green or brown in color

* BILATERAL milky discharge: most common cause is pregnancy,

Also consider hyperprolactinemia: caused by tumors, medications, hypothyroidism, etc.

Concerning breast discharge

non-milky discharge

clear to bloody in color

unilateral

from a single duct

Breast Lumps:

in young women most often not cancer

- usually fiboadenomas or cysts

in those older than 55, 85% of breast masses are malignant

suspicious for malignancy:

non-discrete, borders, fixed, non-tender, retractions, dimpling, lesion/sore on breast, paget's disease (rash on breast/nipple), pain

mammogram vs US

US: can tell difference between solid mass vs cystic mass

Mammography: sees architectural distortion, calcifications, masses

younger women usually get US, older women get mammogram.

Fibroadenoma vs cyst

Fibroadenoma: smooth, round, non-tender, movable, firm

cyst: fluid-filled, tender, moveable

After US biopsy is required to differentiate solid and cystic masses. If fibroadenoma under 4 cm you can watch it. if it is over 4 cm, recommended to remove

Modifiable risk factors for osteoporosis

BMI < 21

anorexia

nulliparity

smoking

excessive alcohol

sedentary lifestyle

medications (corticosteroid, methotrexate, etc)

Non-modifiable risk factors

female gender

advanced age

history of fracture during adulthood

family history osteoporosis

hematologic disorders

autoimmune disorders

Strategies to prevent osteoporosis

- calcium intake of 1200 mg/day in postmenopausal women

- Vitamin D intake of 800-1000 IU/day for adults 50+

- weight bearing exercise

- fall prevention

-avoid tobacco

- moderate alcohol intake (fewer than 2 drinks per day for women)

T scores + bone health

-1.0 to -2.5 is osteopenia

-2.5 or worse is osteoporosis

Treatment for osteoporosis is recommended when

BMD T score is -2.5 or less

Women with hip or vertebral fractures

Ostopenia (-1 to -2.5) and has a fracture or is at igh risk for fractures based on history such as medications or immobilization

Fracture Risk Assessment Tool (FRAX)

helps guide treatment for with with osteopenia, and identify those that may benefit from treatment

calculates the 10 year probability for hip fracture and 10 year probability for any major osteoporotic fracture

if hip fracture probability is >3% or the major fracture risk is >20%, medication therapy is recommended.

Medications for Osteoporosis

Estrogen: PREVENTATIVE ONLY! Not for treatment

Calcitonin, Forteo and Prolia are for treatment only

all others for both prevention and treatment (Evista, Boniva, Avtonel, Reclast, fosamax)

table pg 278

Most rapid bone loss occurs

In the first year after menopause, lose 1-5%, then slows to approximately 1% per year

page 163 Know terms of sexual orientation

page 266: know recommendations for Hormone therapy use

Breast mass characteristics 365

types of placenta previa pg 815