Med Surg & OB test 1

MED SURG: intro, DM & peri-op/respiratory -- OB: prenatal development + Pregnancy changes, prenatal care + infections, Labor and delivery

conception

AKA fetilization, when egg and sperm join

when does conception occur

begins with ovulation, ends with fertilized egg implanting in uterus ( 12-24 hours after ovulation)

fertilization

the moment the sperm enters the egg, the genetic material combine to form single cell → FORMS ZYGOTE

where does fertilization occur

in the outer 1/3 of fallopian tube

implantation

when blastocyst attaches to uterine lining

blastocyst

when zygote multiplies into ~100 cells and travels to uterus after ~ 1 week → the structure of evolving embryo.

when does implantation occur

begins 6-10 days after fertilization and completed by 12-14 days

what can implantation cause

implantation bleeding

ectopic pregnancy

VERY DANGEROUS, when fertilized egg implants outside main cavity of the uterus, most often in fallopian tube

3 stages of development in pregnancy

ovum stage

embryo stage

fetus stage

ovum stage

weeks 1+2 of pregnancy (from LMP), where the zygote is created and cells rapidly divide forming a blastocyst.

embryo stage

weeks 3-8, blastocyst implants, amniotic sac and placenta form, Neural tube develops into brain and spinal cord. All major organs devleoping and umbilical cord formed.

fetus stage

weeks 9-40+, includes both 2nd and 3rd trimester —> period of rapid development

effect of teratogens on fetal development stages

ovum → not susceptible, often mothers do not know they are pregnant

embryo → MOST VULNERABLE

fetus → less sensitive

weeks of 1st trimester

week 1-13

weeks of 2nd trimester

14-27

3rd trimester

28-40 weeks

dizygotic twins

fraternal twins : 2 separate eggs, 2 separate sperm

monozygotic twins

identical twins, from 1 egg and 1 sperm → formed 2 embryo thru cell division

Di/Di twins (Dichorionic, Diamniotic)

-each twin (baby) has their own amniotic sac and each their own placenta (2 amniotic sac, 2 placenta)

-can be fraternal or identical twins

-LOWEST RISK

Mono/Di twins (monochorionic, diamniotic)

1 placenta, 2 amniotic sacs (each baby has own amniotic sac, have to share placenta)

• ALWAYS IDENTICAL TWINS

• Higher risk bc shared blood supply (thru shared placenta)

Mono/Mono twins (monochorionic, monoamniotic)

1 placenta, 1 amniotic sac (twins have to share both the amniotic sac and placenta)

• ALWAYS IDENTICAL TWINS

• HIGHEST RISK (especially bc of cord entanglement)

what is the age (in weeks) of viability

24 weeks

vernix

“cheese” like coating on baby skins, protects it from amniotic fluid

lanugo

hair like structure on babys skin to hold vernix onto skin and to keep baby warm

what happens at 6 weeks

yolk sac formed

what happens at 8-10 weeks

all organ systems and external structures present and maturing

what happens around week 16 (14-20)

mom begins to feel fetal movement (QUICKENING)

what happens at 24 weeks

alveolar ducts and sacs present —> AGE OF VIABILITY

what happens at 28 weeks

eyes open, suck reflex begins

what is the function of the placenta for the baby

acts as babies LUNGS AND LIVER

• delivery of o2 and nutrients to baby from placenta

• waste from baby eliminated through mothers body

Fetal Circulation shunts

ductus venosus

foamen ovale

ductus arteriosus

ductus venosus

shunt from umbilical vein to fetal IVC, to bypass fetal liver bringing oxygenated blood straight to IVC to get pumped around fetus.

• skips over capillary beds of liver, so the highest amount of O2 can circulate

formamen ovale

opening between the right and left atria, shunts highly oxygenated blood from R→L atria, bypassing the R. ventricle and non-functional fetal lungs

ductus arteriosus

shunt connecting pulmonary artery (which normally brings blood to lungs) to aorta → BYPASSING underdeveloped fetal lungs

Amniotic fluid functions

cushion for fetus, thermoregulation, antibacterial properties, allows movement, assists in lung development, prevents umbilical cord compression

composition of amniotic fluid in 1st trimester

mostly maternal blood plasma

composition of amniotic fluid in 2nd and 3rd trimesters

fetal lung fluid and urine → baby breathes and swallows fluid, using lungs before peeing it out

average volume of amniotic fluid in term pregnancy

~800 mLs

Polyhydramnios

too much amniotic fluid, >2 L of fluid

what is common cause of polyhydramnios

maternal diabetes

what is oligohydramnios

too little amniotic fluid, <300 mLs

common cause oligohydramnios

PROM, early water breaking

Placenta development

develops at site of implantation, structure is completed by week 12 and thickens/grows weeks 20-40

functions of placenta

provides metabolic and nutrient (GAS) exchange between fetus and maternal circulation (PLACENTA = FETAL LUNGS AND LIVER). It also produces hormones

relationship between placenta (SIZE) and postpartum bleeding/hemmhorrage

post-birth bleeding occurs at site of placental attachment

• THE LARGER THE PLACENTA = MORE BLEEDING

contents of umbilical cord

2 arteries —> AVA of umbilical cord

1 vein

whartons jelly

what do the arterieS of the umbilical cord do

carry deoxygenated blood from baby back to placenta

what does the umbilical VEIN do

carry highly oxygenated blood from the placenta to baby

what does wharton’s jelly do

prevent the compression of vessels within the cord when inside the womb

• when exposed to the cold temperatures outside after birth, it firms up - clamping down on blood vessels to stop blood flow when its no longer needed

is twisting/spiraling od cord normal?

yes, it is presumed to be caused by fetal movement

pregnancy changes to uterus

uterine growth/expansion powered by ESTROGEN AND PROGESTERONE

cervical changes of pregnancy

cervix stays firm/closed to maintain pregnancy

• MUCOUS PLUG forms early on to prevent infection (or things entering past cervix)

Throughout the pregnancy, it changes to soft elastic tissue that can dilate fully for birth

Goodell’s Sign

GOOD & SOFT

-around 6 weeks, increased vascularity = softening of cervix

vaginal changes of pregnancy

thickening of vaginal mucosa, increase in vaginal secretions (white/greyish)

Chadwick’s Sign

bluish coloration of vagina d/t increased vascularity

breast changes of pregnancy

enlargement, darkening of areola, striae (stretch marks), and colostrum production in 2nd trimester

cardiovascular changes of pregnancy

increase in blood volume, increase in HR, decrease in BP in 2nd trimester, hypercoaguable state (from hormones)

& increase in uterus size causes:

• stasis of blood flow in lower extremities

• dependent edema, varicosities, vena cava syndrome, postural hypotension

lab changes from pregnancy

increase in RBC volume (increased iron need), increased plasma volume (normal physiologic anemia of pregnancy = decreased H&H), increased WBCs in 3rd trimester

respiratory system changes of pregnancy

increased oxygen requirements = increased RR, breathing changes from abdominal to chest, chest cavity expands, epistaxis & nasal stuffiness r/t hormone induced anemia.

GI system changes of pregnancy

N/V (morning sickness) common in 1st trimester, bleeding gums & gingivitis, increased salivation (ptyalism), delayed gastric empyting = heartburn, bloating, constipation, hemorrhoids and gallstones

GU system & fluid/electrolytes

urinary frequency increases, GFR inceases by 50% bc increased blood volume, elongation of ureters = stasis of urine = increased risk of UTIs.

-Women can become dehydrated quickly and severely when pregnant!!!!!

skin and hair changes r/t pregnancy

areolas darker, linea nigra from umbilicus, cloasma/melasma (mask of pregnancy), striae gravidarum (stretch marks), increased hair growth during pregnancy, hair loss postpartum

musculoskeletal changes r/t pregnancy

lumbar lordosis, shift of center of gravity, relaxation of pelvic joints, diastasis recti abdominis

nutrition in pregnancy

avoid fish & high mercury foods, avoid common food borne illness food, get plenty of folate (take pre-pregnancy if able!! neural tube defects present week 3/4)

healthy weight gain in pregnancy

normal pre pregnancy weight = 25-35 weight gain

overweight/obese = 15-25 weight gain

when to use Naegele’s rule

how to calculate EDD/EDB/EDC = due date from LMP

Naegele’s rule equation

for month of EDD: month of period - 3 months

for day of EDD: last period + 7 days

year of EDD = +1 year

calculate EDD from LMP of May 21st, 2019

Feb 28, 2020

how do you say pt is 5 months and 2 weeks pregnancy

20+2 (20 weeks + 2 days)

when to use G’s & P’s of pt

to get a quick picture of pts birthing history, if the number of prengnacies & deliveries do not line up = use more comprehensive GTPAL

G’s & P’s definitions

G= gravida refers to pregnancies not to the fetus (twins = 1 pregnancy and birth)

P = para refers to deliveries after 20 weeks

GTPAL: what does G mean

gravida = number of pregnancies, including current pregnancy

GTPAL: what does T mean

term births, birth after 37 weeks

GTPAL: what does P mean

number of preterm births, between 20-36+6(days) weeks

GTPAL: what does A mean

abortions before 20 weeks (spontaneous (miscarriage) or elective)

GTPAL: what does L mean

number of current living children

when does ABO incompatability occur

when mom is O+ and baby is not O type blood

• leads to fetal RBC lysis by moms anti-A & anti-B antibodies can attack baby RBCs if blood mixes

• RBC lysis can cause jaundice in new borns

is there prevention for ABO incompatability

no, it is not usually too serious for baby, just usually an increased risk of jaundice

RH-isoimmunization/ RH incompatability

only happens when mom is RH- and baby is Rh+, if blood mix sensitization can occur & moms immune system (Anti D/Anti-Rh) antibodies will attack and lyse fetal RBCs.

does Rh sensitization/isoimmunization increase risk with each pregnancy

each pregnancy is affected more seriously → potentially fatal for the baby

• once the mom is sensititized (thru mixing of blood), she will always have the anti-D antibodies that will attack Rh+ babies

prevention of Rh isoimmunization

if mom is Rh- and baby Rh+, mom will get RhoGAM in 3rd trimester and within 72 hours of deliery.

Chlamydia S+S & complications

S+S: often asymptomatic

Complications:

• maternal = untreated can lead to infertility, ectopic pregnancy & PID (pelvic inflammatory disease)

• fetal - opthalmia neonatorum (infxn of eye/eyelid)

Chylamidia screening, trtmt

routine screening of asymptomatic mothers, can re-screen at end of preg with high risk behaviors

trtmt = ABX, especially erythromycin for newborns on eyelids

Gonorrhea S+S

S+S: often asymptomatic, pelvic pain, longer menses, may have purulent discharge (vagina rectum, throat)

Gonorrhea complications

maternal: untreated can lead to ectopic pregnancy, infertility, pelvic inflammatory disease, preterm labor, PROM, chorioamniotis, sepsis

• can spread from vagina to rectum

fetal: IUGR, sepsis

screening and treatment of gonorrhea

routine screening ofn asymptomatic and pregnant women → swab vagina, rectum, throat

trtmt = antibiotics

Syphilis transmission

transmits by entry in subq tissue through microscopic abrasions & vertical tranmssion during any gestation of pregnancy

syphilis S+S/maternal complications

STAGE 1: primary, lesions “chancre” present on skin

• CONTAGIOUS

STAGE 2: secondary, maculopapular rash on PALMS and SOLES and generalized LYMPHADENOPATHY (swollen lymph nodes). Wart like infections lesions on outer genito-rectal area

• CONTAGIOUS

LATENT: if no treatment is recieved, no symptoms occur but still in body

STAGE 3: tertiary, only 1/3 develop it from latent, causes neurological/cardiovascular involvement

• NOT CONTAGIOUS

Fetal/newborn complications

transmission occurs through placenta to fetus. Can cause still birth, preterm delivery and congenital syphilis:

• maculopapular lesions, punched out, pale, blistered lesions on ears and nasal bridge, skin peeling lesions on feet and palm

Screening & trtmt for syphilis

RPR testing - looks for syphilis antibodies, but gets false positive for other disease antibodies.

Treponema testing - sensitive for only syphilis antibodies

Tx = PCN only when pregnant

HPV (Human papillomavirus) - Genital Warts S+S

lesions to genito-rectal area, looks like cauliflower-like mass. they are more common in pregnancy and grow more throughout the pregnancy

Complications of HPV

maternal = large lesions can inhibit vvaginal delivery, can lead to cancer of cervix, anus, penis or mouth

fetus = neonatal infxn is rare

screening & trtmt for HPV

tx for warts = cryotherapy (freeze them off)

• HPV is not curable

dx through pap-smear

Prevention: gardasil prevents some types of HPV

Herpes Simplex Virus (HSV1, HSV2) S+S

HSV1(oral), HSV2 (gential)

initial infxn = multiple painful lesions, fever, chills, malaise

“fever blisters” that crust over

subsequent outbreak = tingling/burning where lesions will form

complications from Herpes (HSV1&2)

maternal: cannot deliver vaginally if genital lesions present, primary infxn during 1st trimester = increased risk of miscarriage

fetal: mainly affects liver and lungs →if culture positive for herpes, tc IV acyclovir!!

• HIGH MORTALITY RATE

screening/trtmt for herpes (HSV1+2)

diagnosis through inspection and viral culture.

tx: acyclovir for symptoms not cure

• acyclovir given preventative if pt has HSV (even if not active infxn) to prevent vaginal outbreak

GBS: group beta streptococcus info

NOT an STI, part of normal vaginal flora, can spread to baby and cause infxn

GBS S+S

maternal = usually none

• if cause of UTI, will treat during labor even if negative swab

GBS complications

Maternal: UTI, chorioamniotis, rarely preterm labor

fetal:

• early onset GBS sepsis (1st week) causes hypothermia, respiratory distress, poor feeds, lethargy, cyanosis

• late onset GBS sepsis (more serious), can ause meingitis along with early onset GBS symptoms