Exam #1 NURS230

S/S and complications of Chlamydia

-S/S

• Usually asymptomatic so routine screening is essential

• Abdominal pain if PID occurs

-Complications

• Acute salpingitis

• Pelvic inflammatory disease (PID)

  • Most serious complication of chlamydial infections, and past chlamydial infections, is associated with an increased risk of acquiring HIV infection

S/S and complications of Gonorrhea

-S/S

• Women often asymptomatic

• Screening is crucial

• When symptoms are present, they are often less specific than symptoms in men

  • Purulent endocervical discharge, but this is more often minimal or absent

  • Mucopurulent drainage: This is characterized by thick, purulent (pus-like), and something malodorous vaginal discharge

  • Menstrual irregularities or women may report pain. It may be chronic or acute severe pelvic or lower abdominal pain or longer, more painful menses

  • Following symptoms may occur infrequently: dysuria, vague abdominal pain, or low backache prompt a woman to seek care

  • Rectal gonorrhea may be completely asymptomatic or have severe symptoms with profuse purulent anal discharge, rectal pain, and blood in the stool

-Complications

• Perinatal complications of gonococcal infection

  • Prelabor rupture of membranes, preterm birth, chorioamnionitis, neonatal sepsis, intrauterine growth restriction, and maternal postpartum sepsis

• Gonococcal infections in pregnancy can affect the pregnant woman and the fetus

• Ophthalmia neonatorum, a neonatal gonococcal infection, it is highly contagious, and if left untreated, it may lead to blindness of the newborn

S/S and complications of Pelvic Inflammatory Disease (PID)

-S/S

• Mucopurulent drainage

• Cramping or pain

-Complications

• Tubal damage and infertility: Inflammation and infection cause scar tissue adhesions that can block or kink the fallopian tubes. While sperm may pass through, a larger fertilized egg cannot complete the journey to the uterus.

• Ectopic pregnancy: Damaged tubes with adhesions prevent the fertilized egg from reaching the uterine cavity, resulting in tubal implantation. This can completely destroy the tube and is life-threatening if untreated.

• Hydrosalpinx: Fluid buildup inside damaged fallopian tubes. This fluid is toxic to embryos and negatively impacts pregnancy rates in women undergoing infertility treatment.

• Chronic pelvic pain: Ongoing inflammation and adhesions

• Tubal factor infertility: Past chlamydial infections (the most common cause of PID) are strongly associated with increased risk of infertility

S/S and complications of Syphilis

-S/S

• Primary Phase: This stage typically begins 5 to 90 days after the initial sexual encounter. The hallmark symptom is a chancre, which is a sore or lesion located in the reproductive area, such as the penis, labia, or vulva. This sore will eventually go away on its own.

• Secondary Phase: This stage occurs 6 weeks to 6 months later. Key symptoms include:

  • Systemic rash: A classic indicator of syphilis is a rash that appears on the palms of the hands and soles of the feet.

  • Genital lesions: Infectious lesions may appear throughout the genital area.

  • Flu-like symptoms: Patients may experience mild fever or general malaise.

  • Like the primary stage, these symptoms are self-limiting and will eventually clear up, leading the patient to believe the infection is gone.

• Tertiary Phase: This final stage can take years or even decades to manifest after the initial infection

-Complications

• Neurological Complications: During the tertiary phase, the disease can cause significant damage to the nervous system.

• Systemic Damage: If not treated with penicillin, the disease can lead to widespread systemic issues.

• Death: Syphilis can be fatal if the infection is allowed to progress to its final stages without medical intervention.

• Congenital Risks: While not detailed extensively in the syphilis section, the sources note that "torch infections" (which includes syphilis) acquired during pregnancy can have detrimental effects on a developing fetus

• Neurologic, cardiovascular, musculoskeletal, or multiple organ–system complications can develop in the tertiary stage

S/S and complications of Human Papillomavirus (HPV)

-Signs and symptoms

• Asymptomatic: Many individuals have no symptoms at all and may not realize they are infected.

• Genital Warts: These are benign (non-cancerous) growths that can be unsightly, uncomfortable, and embarrassing. They may hurt or irritate the area and often interfere with sexuality.

• Pregnancy-Related Changes: Warts often become more obvious or appear during pregnancy due to the mother's slight immunosuppression.

• Cervical Cell Changes: Internally, HPV can cause hyperplastic or neoplastic cell changes (abnormal cell growth) on the cervix, which are detected during a Pap smear

• "Bumps" on vulva or labia (patient-reported)

• Small lesions: 2-3 mm in diameter, 10-15 mm in height

• Appearance: Soft, papillary swellings occurring singly or in clusters

• Location in women: Posterior introitus (most common), buttocks, vulva, vagina, anus, and cervix

• Long-duration infections: May appear as cauliflower-like mass

• Moist areas: Multiple fine finger-like projections

• Cervical lesions: Flat-topped papules (1-4 mm diameter), often only visible under magnification

• Color: Flesh-colored or slightly darker based on skin tone

• Usually painless but may be uncomfortable when very large, inflamed, or ulcerated

-Complications

• Cervical Cancer: HPV is the predominant cause of cervical cancer. It causes slow-growing malignant changes in cervical cells.

  • Can be cancers of the cervix, vagina, vulva, anus, penis, and oropharynx

• Persistent Infection: In some patients, particularly those with compromised immune systems, the infection can live in their cells for the rest of their lives, meaning they remain infectious.

• Surgical Interventions: If abnormal cervical cells persist or worsen, complications may lead to the need for advanced diagnostic procedures like a colposcopy or major surgeries, such as a partial hysterectomy to remove the cervix or entire uterus

S/S and complications of Herpes Simplex Virus (HSV)

• Herpes simplex virus 1 (HSV-1) → Transmitted non-sexually

• Herpes simplex virus 2 (HSV-2) → Transmitted sexually

-Signs and symptoms

• Initial Outbreak: The first infection, particularly with HSV-2, is often severe and can be devastating. Symptoms include:

  • Painful Lesions: These appear as vesicles or blisters filled with a high concentration of the virus.

  • Flu-like Symptoms: Patients often experience fever and chills.

  • Severe Dysuria: Urination can cause a severe burning sensation, leading some patients to avoid urinating because of the intense pain.

  • A history of having viral symptoms such as malaise, headache, fever, or myalgia is suggestive. Local symptoms such as vulvar pain, dysuria, itching, or burning at the site of infection and painful genital lesions that heal spontaneously are also highly suggestive of HSV infection.

• Recurring Outbreaks: While medications like acyclovir can suppress outbreaks and shorten their duration, the virus remains in the body for life.

  • Painful recurrent genital ulcers

  • Generally less severe than primaru infection

-Complications

• Neonatal Infection: If a mother has an active infection, the virus can be passed to the infant during passage through the vaginal canal. This can lead to a herpes viral infection of the eye in the newborn.

• Detrimental Fetal Effects: HSV is classified as a "torch infection," meaning that if acquired during pregnancy, it can have serious, detrimental effects on the developing fetus.

• Surgical Intervention (C-Section): If a woman in labor has visible, active lesions, a C-section is automatically advised to prevent the baby from coming into contact with the virus in the vaginal canal. If no lesions are present, a vaginal delivery may be allowed.

• Psychological Impact: Because viral STIs like herpes are recurring and currently incurable, they can carry a significant amount of stigma and shame for the patient

• Viremia in the Context of HSV and Pregnancy

  In relation to HSV (herpes simplex virus) during pregnancy:

  • Primary HSV infection can cause viremia in the pregnant woman

  • During viremia, the virus circulates in the maternal bloodstream

  • This creates a risk for transplacental transmission to the fetus

  • However, congenital HSV infection through this route is rare

S/S and complications of Hepatitis A

-Transmission Routes

• Fecal-oral route

• Contaminated sources (like water or shellfish)

• Risk factors are unhours populations

-S/S

• Characterized by flulike symptoms with malaise, fatigue, anorexia, nausea, pruritus, fever, and right upper quadrant pain

-Complications

Dehydration:

• Can result from severe nausea and vomiting

• May require hospitalization for fluid replacement

Acute Liver Failure:

• Rare but serious complication

• Requires hospitalization

• Women showing signs or symptoms need immediate medical attention

S/S and complications of Hepatitis B

-Identified as acute or chronic based on the presence of specific antibodies and antigens in blood tests

-S/S

• Common Symptoms:

  • Arthralgias (joint pain) and arthritis

  • Lassitude (weakness/fatigue)

  • Anorexia (loss of appetite)

  • Nausea and vomiting

  • Headache

  • Fever

  • Mild abdominal pain

  Later-Stage Symptoms:

  • Clay-colored stools

  • Dark urine

  • Increased abdominal pain

  • Jaundice

-Complications

• Most threatening to the fetus and neonate

• Disease of the liver and often a silent infection

• Chronic HBV Infection:

• Persistence of HBsAg in the blood indicates chronic infection

• Can lead to chronic liver disease

• Requires referral to specialized care provider for evaluation and management

• FDA-approved therapeutic agents can result in sustained suppression of HBV replication and remission of liver disease

Perinatal Transmission (Most Significant Complication):

• HBV is the virus most threatening to the fetus and neonate

• Transmission most often occurs in infants of mothers with acute infection in late third trimester or during intrapartum/postpartum period

• Exposure through HBsAg-positive vaginal secretions, blood, amniotic fluid, saliva, and breast milk

Neonatal Management:

• Infants born to HBsAg-positive mothers should receive HBV vaccine and HBIG within 12 hours after birth

• Must complete recommended vaccine series followed by postvaccination serologic testing

• Universal HBV immunization recommended for all neonates before hospital discharge

-Note

• Hepatitis B is often a "silent infection" - many people have no symptoms

• The course can be sudden and severe in adults

• Some individuals become asymptomatic chronic HBV carriers with persistence of HBsAg

• All pregnant women should be screened for HBsAg at firts prenatal visit

S/S and complications of Hepatitis C

-S/S

• Fatigue

• Muscle weakness

• Jaundice

• Pruritus

-Complications

• Liver fibrosis/cirrhosis

• GI varices

• Hepatocellular carcinoma

S/S and complications of Human immunodeficiency virus (HIV)

-S/S (Mnemonic= Feverish Hikers Need More Gear; Muscles Numb, Digestion Weak, Skin Reacts)

• Fever

• Headache

• Night sweats

• Malaise

• Generalized lymphadenopathy

• Myalgias

• Nausea

• Diarrhea

• Weight loss

• Sore throat

• Rash

-Complications

• Frequent opportunistic infections, etc.

• AIDs

Endometriosis S/S

Pain Characteristics:

• Pelvic pain - most common symptom (present in 33% of women with chronic pelvic pain)

  • Specifically, deep pelvic dyspareunia

• Pain often begins a few days before menses

• Can be present at ovulation and continue through the first days of menses

• May start after menstrual flow has begun

• Dull lower abdominal aching that radiates to the back or thighs

• Acyclic pain (especially in adolescents)

Menstrual-Related Symptoms:

• Dysmenorrhea (painful menstruation)

• Abnormal vaginal bleeding

Other Common Symptoms:

• Feelings of bloating or pelvic fullness

• Gastrointestinal symptoms: diarrhea, constipation, and urgency (especially in adolescents)

• Migraines (more common in adolescents with endometriosis)

Fertility Impact:

• 30% to 45% of infertile women have endometriosis

Risks for breast cancer

Nonmodifiable Risk Factors

Hormonal and Reproductive History:

• Menarche before age 12 - longer exposure to hormones

• Menopause after age 55 - longer exposure to hormones

• Length of time on unopposed estrogen - significant risk factor

• Never having children

• First pregnancy after age 30

• Not breastfeeding

Personal and Family History:

• Personal history of breast cancer - constant risk for developing a second malignancy

• Family history of breast or ovarian cancer in a first-degree relative or multiple relatives

• BRCA1 or BRCA2 mutations:

  • 55% to 72% lifetime risk with BRCA1 mutation

  • 45% to 69% lifetime risk with BRCA2 mutation

  • General population: ~13% lifetime risk

Other Factors:

• Female sex

• Increasing age

• Higher breast density - increases risk and makes mammography interpretation more difficult

• Fibrocystic disease with proliferative diseases with atypia

• Atypical hyperplasia (ADH or ALH) - 4 to 5 times greater risk

• Diethylstilbestrol (DES) exposure - drug used decades ago to maintain pregnancy

---

Modifiable Risk Factors

Lifestyle Factors:

• Overweight or obesity after menopause

• Moderate to high alcohol consumption

• Physical inactivity

Hormone Use:

• Hormone replacement therapy during menopause for more than 5 years

• Oral contraceptives

Side effects and drug interactions with IUDs

-Side effects

• Heavier periods with Paragrad, periods, cramping

-Drug Interactions

• ??

Side effects and drug interactions with Nexplanon (LARCs or long active reversible contraceptives)

-Side effects

• Irregular bleeding

-Drug interactions

• ?

Side effects and drug interactions with Progestin-only contraception (Short acting/hormonal)

-Side effects

• Irregular bleeding/spotting

• Breast tenderness

• Acne

• Lower libido

• Headaches

• Nausea

• Ovarian cysts

• Depression

-Drug interactions

• ?

Side effects and drug interactions with Oral contraceptives

-Side effects

• Sore breasts

• Nausea

• Spotting

• Decreased sex drive

-Drug interactions

• ?

Drug interactions with COCs

-Anticonvulsants (Dilantin) → reduces effects of COCs

-Fosamprenavir, rifampin, or rifabutin (HIV/TB medications)

Contraindications to COCs

-History of thrombosis

-Stroke

-Heart disease/hypertension

-Breast cancer

-Positive antiphospholipid antibodies

-Migraines with aura

-Prolonged immobility (Surgery, MS, etc.)

-Diabetes with vascular complications

-Gallbladder

-Disease

-Hepatic disease or disorder

-Pregnancy

-Use of fosamprenavier, rifampin, or rifabutin (HIV/TB meds)

-Use of some anticonvulsants (Dilantin)

-Less than 6-week PP (postpartum)

-Smoker over 35 (vasoconstriction and compromised vascular system)

Signs of pregnancy

-Presumptive

• Those changes felt by the woman

  • Nausea

  • Vomiting

  • Breast tenderness

  • Fatigue

-Probable

• Those changes observed by an examiner, can still be attributed to other causes!

  • Chadwick’s: Blue/violet color of vaginal mucosa/cervic

  • Hegar’s: Softening of the lower uterine segment

  • Goodell’s sign: Softening of the tip of cervix

  • Pregnancy test (urine or serum)

-Positive

• Those signs attributed only to presence of a fetus

  • Fetal movement on ultrasound, fetal heartbeat

Anemia in pregnancy

-Dilutional anemia, especially common in 2nd trimester

• Hgb = RBC/plasma volume

  • Plasma volume increases more than RBC mass

  • Should not decrease less than 11 g/dL (normal is 12 g/dL)

  • If lower, investigate pathological anemia instead of physiologic anemia

• Iron and folate supplementation can be recommended

• Physiologic anemia of pregnancy is a normal occurrence where hemoglobin and hematocrit decrease due to greater plasma volume expansion compared to red blood cell production. This is most noticeable in the second trimester.

Complications:

• Associated with preterm birth and low-birth-weight infants

• Fetus usually receives adequate iron stores even from anemic mother, further depleting maternal iron levels

What can be normal findings for a patient in 1st trimester (1-13 weeks)?

Uterine Changes:

• Uterus remains a pelvic organ until 12 weeks

• Size progression: large hen's egg (7 weeks) → orange (10 weeks) → grapefruit (12 weeks)

• Changes from pear shape to spherical/globular shape

• Can be palpated above symphysis pubis between 12-14 weeks

Cardiovascular:

• Heart rate begins increasing at ~5 weeks

• Increase of 15-20 beats/min above baseline by 32 weeks (persists to term)

• Increased frequency of isolated premature atrial and ventricular contractions

Respiratory:

• Maternal oxygen consumption begins increasing

• Early structural adaptations begin

Common Symptoms:

• Nausea and vomiting

• Fatigue

• Breast tenderness

• Urinary frequency

-Fetus’s organs are starting to form

What can be normal findings for a patient in 2nd trimester (14-27 weeks)?

Uterine Changes:

• Pregnancy may "show" after week 14 (varies by body type and parity)

• Uterus rises to umbilicus level by 20-22 weeks

• Uterus rotates to the right as it enlarges

• Enlargement primarily from mechanical pressure of growing fetus

Cardiovascular:

• Audible splitting of S1 and S2 by end of first trimester/early second

• Third heart sound (S3) after midpregnancy

• Systolic ejection murmurs in ~96% of women (most audible over left sternal border)

• Heart elevated upward and rotated forward to left

• PMI shifted upward and laterally 1-1.5 cm

Respiratory:

• Physiologic dyspnea common (begins first or second trimester)

• Diaphragm rises up to 4 cm

• Costal angle increases; lower rib cage flares out

• Transverse thoracic diameter increases ~2 cm

• Chest breathing replaces abdominal breathing

-Fetus’s organ system are maturing

What can be normal findings for a patient in 3rd trimester (More than 28 weeks)?

Uterine Changes:

• Fundus nearly reaches xiphoid process at term

• Lightening occurs weeks 38-40 (fundal height decreases as fetus descends)

  • Nulliparas: ~2 weeks before labor

  • Multiparas: at labor onset

Cardiovascular:

• Heart rate remains 15-20 beats/min above baseline

• All cardiovascular changes persist until term

Respiratory:

• Oxygen consumption reaches 40% above nonpregnant levels by term

• Mechanical pressure increases dyspnea in late pregnancy

-Getting ready/into position, etc. for delivery

How do you determine gestational age/due date with Naegele's rule?

Naegele's Rule Calculation

The Formula:

1. Identify the first day of the last menstrual period (LMP)

2. Subtract 3 months from that date

3. Add 7 days to the result

4. Add 1 year (if needed)

Example:

• LMP: January 10, 2024

• Subtract 3 months: October 10, 2023

• Add 7 days: October 17, 2023

• Add 1 year: October 17, 2024 (EDB)

---

Important Assumptions

Naegele's rule assumes:

• 28-day menstrual cycle

• Ovulation/fertilization occurred on day 14 of the cycle

• Accurate recall of LMP date

---

Key Points About Accuracy

Limitations:

• Only about 5% of women give birth spontaneously on the EDB calculated by Naegele's rule

• Most births occur within 7 days before to 7 days after the EDB

Most Accurate Method:

• First trimester ultrasound measurement of the embryo or fetus provides the most accurate EDB assessment

• The EDB is determined based on both the LMP date AND first accurate ultrasound examination

How do you determine gestational age/due date?

Methods for Determining Gestational Age and Due Date

Most Accurate Method: First Trimester Ultrasound

• Crown-rump length or maximum embryo length measured during first trimester

• Commonly accepted as the most accurate method for determining gestational age

• The estimated date of birth (EDB) is determined based on both the LMP date AND first accurate ultrasound examination

After First Trimester Ultrasound:

• Measurements used: biparietal diameter (BPD), head circumference, abdominal circumference, and femur length

• Combination of these measurements is the most accepted method after the first trimester

What is Gravidity, Gravida, Parity, Primipara, Multipara, and Nullipara

-Gravidity: Pregnancy

-Gravida: Whoman who is pregnant

-Parity: Number of pregnancies in which fetus or fetuses have reached viability, not number of fetuses (e.g., twins) born

• Whether fetus is born alive or is still born (fetus who shows no signs of life at birth) after viability is reached does not affect parity

• Gestational definition of viability is reaching 20 weeks gestation

• Vs. ability to survive extrauterine life is approximately 22-23 weeks

-Primara: Woman who has completed one pregnancy with fetus or fetuses who have reached stage of fetal viability

-Multipara: Woman who has completed two or more pregnancies to stage of fetal viability

-Nullipara: Woman who have not completed a pregnancy with fetus or fetuses who have reached stage of fetal viability

What does GTPAL stand for?

-Gravidity/Gravida (number of pregnancies, including this one)

-Term (pregnancies, 37 weeks 0 days and beyond)

-Preterm (pregnancies, between 20 weeks 0 days and 36 weeks 6 days gestation)

-Abortion (Number of pregnancies that ended in miscarriage or elective termination before 20 weeks or weighted less than 500 g at birth)

-Living (Number of children currently living)

Where is the fundus at 20 weeks?

-Around the umbilicus

Important nutrition advice in pregnancy

Key Nutrition Recommendations

Preconception & Early Pregnancy:

• Folic acid: 0.4 mg (400 mcg) daily for all women of childbearing age

• During pregnancy: Increase to 0.6 mg (600 mcg) daily, especially in first trimester

• History of NTD: 4 mg daily starting 1 month before conception through first trimester

• Critical for preventing neural tube defects (spina bifida, anencephaly)

Iron Supplementation:

• Recommended daily allowance: 27 mg during pregnancy

• Supports maternal RBC expansion and fetal iron transfer

• May be better tolerated if started after first trimester due to nausea

• Include dietary iron sources even when taking supplements

Protein Intake:

• 71 g/day during pregnancy (increased from 46 g/day for nonpregnant adults)

• Essential for fetal growth, placental development, and maternal tissue expansion

• Sources: milk, meat, eggs, cheese, legumes, whole grains, nuts

---

General Dietary Guidance

Prenatal Vitamins:

• Multiple micronutrient (MMN) supplement recommended before and throughout pregnancy

• Especially important in first trimester when adequate folate and iron intake is less likely

• Important: Supplements don't replace the need for a nutritious, well-balanced diet

Dietary Approach:

• Consume a varied diet rich in vitamins and minerals

• Counseling should begin in early prenatal care and continue throughout pregnancy

• Most nutrient needs (except folate and iron) can be met through dietary sources alone

Foods to Promote Iron Absorption:

• Certain foods can enhance or inhibit iron absorption from supplements

• Discuss optimal timing and food combinations with healthcare provider

---

Special Considerations

Supplements are especially important for women with:

• Known nutritional risk factors

• Poor dietary intake

• History of anemia

• Multiple gestations

Appendicitis in pregnancy

Appendicitis in Pregnancy

Incidence & Diagnosis Challenges:

• Most common nonobstetric surgical emergency during pregnancy

• Occurs in approximately 1 in 1,000 pregnancies

• Diagnosis often delayed because symptoms mimic normal pregnancy changes (nausea, vomiting, elevated WBC)

• Rupture occurs in up to 40% of pregnant women with appendicitis due to delayed diagnosis

---

Clinical Presentation

Most Reliable Symptom:

• Right lower quadrant abdominal pain (regardless of gestational age)

Less Reliable Indicators in Pregnancy:

• Nausea and vomiting (common in normal pregnancy)

• Loss of appetite (not reliable)

• Fever, tachycardia, dry tongue, localized tenderness (less likely than in nonpregnant individuals)

• WBC count (not helpful due to physiologic increase in pregnancy)

Anatomic Changes:

• Appendix is displaced upward and laterally as pregnancy progresses

• Pushed high and to the right, away from McBurney point

• Makes diagnosis more difficult

---

Diagnostic Workup

Initial Tests:

• Urinalysis (rule out UTI)

• Chest x-ray (rule out right lower lobe pneumonia)

• Both conditions can cause lower abdominal pain

Imaging:

• Ultrasonography preferred during pregnancy (avoids fetal radiation exposure)

• MRI is appropriate next step if ultrasound doesn't confirm diagnosis

• CT scan avoided due to radiation exposure (though it's the test of choice in nonpregnant patients)

---

Treatment

Surgical Management:

• Prompt surgical intervention is standard treatment

• Appendectomy recommended even if appendicitis not evident at surgery

• Performed via laparoscopy or laparotomy (surgeon's discretion)

Antibiotic Therapy:

• Often administered for uncomplicated appendicitis

• Definitely necessary if rupture, abscess, or peritonitis present

• Safe options during pregnancy: penicillins, cephalosporins, metronidazole

---

Key Nursing Considerations

• Maintain high index of suspicion for appendicitis in pregnant women with abdominal pain

• Understand that typical signs may be absent or altered

• Recognize urgency due to high rupture risk

• Support timely diagnostic workup and surgical intervention

Cholecystitis in pregnancy

Cholecystitis in Pregnancy

Incidence & Pathophysiology:

• Cholelithiasis (gallstones) occurs in 1-3% of pregnant women

• Pregnancy increases risk due to elevated estrogen and progesterone levels, which encourage stone formation and slow gallbladder emptying

• Cholecystitis (gallbladder inflammation) usually occurs when a gallstone obstructs the cystic duct

• Third most common indication for nonobstetric surgery in pregnancy (~4 cases per 10,000 pregnancies)

---

Clinical Presentation

Cholelithiasis (Gallstones):

• Most are asymptomatic during pregnancy

• First symptom: biliary colic with epigastric or right upper quadrant pain

• Pain may radiate to back or shoulders

• Often triggered after high-fat meals or occurs spontaneously

Cholecystitis (Inflammation):

• Epigastric or right upper quadrant pain (more severe and prolonged than biliary colic)

• Nausea and vomiting

• Fever

---

Management

Conservative Management:

• Most women can be managed conservatively for remainder of pregnancy

• Nutritional counseling emphasized (see dietary modifications below)

• Surgery often postponed until postpartum period

Surgical Intervention:

• Immediate cholecystectomy required for:

  • Recurrent biliary colic

  • Acute cholecystitis

• Laparoscopic cholecystectomy is the preferred procedure

• Can be safely performed in all trimesters (second trimester traditionally considered safest, but improved techniques allow surgery at any time)

• Both laparoscopic and open cholecystectomy are safe options

---

Diagnostic Challenges

• Pregnancy makes diagnosis more difficult due to:

  • Enlarged uterus

  • Displaced internal organs

  • Altered usual signs and symptoms

  • More difficult abdominal palpation

---

Key Nursing Considerations

• Provide nutritional counseling for conservative management

• Educate about avoiding high-fat meals

• Monitor for worsening symptoms requiring surgical intervention

• Support patient through surgical decision-making if needed

Ectopic pregnancy

Definition & Location:

• Fertilized ovum implants outside the uterine cavity

• 70% occur in the ampulla (largest portion of fallopian tube)

• Less common sites: abdominal cavity, ovary, cervix, cesarean scar

• Accounts for 3% of all pregnancy-related maternal deaths in the U.S.

---

Risk Factors

• Previous ectopic pregnancy

• Fallopian tube abnormalities

• Previous genital infections

• Infertility

• Smoking

• Assisted reproductive technology (IVF)

• Previous tubal ligation or IUD use

---

Classic Clinical Manifestations (Before Rupture)

Three Classic Symptoms:

1. Abdominal pain (occurs in almost every case)

   • Begins as dull, lower quadrant pain on one side

   • Progresses from dull → colicky → sharp, stabbing → diffuse, severe pain

2. Delayed menses (1-2 weeks late or lighter than usual)

3. Abnormal vaginal bleeding (mild-to-moderate dark red or brown spotting)

---

After Rupture

Additional Signs:

• Referred shoulder pain (from diaphragmatic irritation due to blood in peritoneal cavity)

• Generalized, one-sided, or deep lower quadrant acute abdominal pain

• Signs of shock: faintness, dizziness (related to intraabdominal bleeding, not necessarily vaginal bleeding)

• Cullen sign: ecchymotic blueness around umbilicus (indicates hemoperitoneum)

---

Diagnosis

Screening Criteria: Every woman with abdominal pain, vaginal spotting/bleeding, AND positive pregnancy test should be screened.

Key Diagnostic Tools:

• Quantitative β-hCG levels

• Transvaginal ultrasound

Discriminatory Zone Concept:

• When β-hCG >1500-2000 mIU/mL, normal intrauterine pregnancy should be visible on transvaginal ultrasound

• If β-hCG >1500 mIU/mL but no intrauterine pregnancy visible → ectopic pregnancy very likely

• β-hCG may be redrawn every 48 hours to assess viability

Differential Diagnosis: Miscarriage, ruptured corpus luteum cyst, appendicitis, salpingitis, ovarian cysts, ovarian torsion, UTI

STIs in pregnancy

STIs in Pregnancy: Key Considerations

Maternal & Fetal Impact:

• STIs cause significant morbidity and mortality during pregnancy

• Maternal consequences: infertility, sterility (lifelong effects)

• Fetal consequences: affect child's length and quality of life

• Outcomes depend on: coinfection with other STIs, timing of infection, and when treatment was initiated

• TORCH infections → group of infections that are capable of crossing the placenta and adversely affecting the fetus

  • T - Toxoplasmosis

  • O - Other infections (hepatitis, HIV)

  • R - Rubella virus

  • C - Cytomegalovirus

  • H - Herpes simplex virus (HSV)

---

Screening Recommendations

HIV:

• Universal screening at initial prenatal visit (opt-out approach)

• Retest in third trimester for high-risk women

• Rapid HIV testing in labor for women with unknown status

• With antiretroviral therapy (ART), mother-to-child transmission reduced to <2%

• ART given orally throughout pregnancy but may increase risk of preterm birth, low birth weight, and stillbirth

Syphilis:

• Screen all pregnant women at first prenatal visit

• Retest early third trimester and at delivery if high risk

• Test all women who deliver stillborn infants

• Partners must be evaluated, tested, and treated

• Up to one-third with early primary syphilis may have nonreactive serologic tests initially

Chlamydia:

• Yearly screening for all sexually active women <25 years

• Screen women ≥25 years if high risk (new/multiple partners)

• All pregnant women <25 years: screen at first prenatal visit

• Pregnant women ≥25 years: screen if at increased risk

• Retest during third trimester if <25 or at risk

• Test of cure 4 weeks after treatment for pregnant women

• Retest within 3 months after treatment

---

Public Health Concern

• 26 million new STI cases in 2018 (nearly half in ages 15-24)

• 61% of chlamydial infections in young women (2019)

• 10-15% of untreated STIs (chlamydia/gonorrhea) lead to pelvic inflammatory disease (PID)

• PID can cause infertility and chronic pelvic pain

Maternal Harms

Immediate Complications:

• Salpingitis (fallopian tube infection) - particularly with gonorrhea in first trimester

• Pelvic inflammatory disease (PID) - 10-15% of untreated chlamydia/gonorrhea cases

• Chorioamnionitis (infection of fetal membranes)

• Postpartum sepsis

• Prelabor rupture of membranes

• Preterm birth

Long-Term Consequences:

• Infertility and sterility (lifelong effects)

• Increased risk of ectopic pregnancy (from past chlamydial infections)

• Chronic pelvic/abdominal pain

• Increased HIV transmission risk - cervical inflammation from chlamydia causes microscopic ulcerations, making HIV acquisition easier

---

Fetal & Neonatal Harms

In Utero Effects:

• Intrauterine growth restriction (IUGR)

• Congenital infection (rare with some STIs like HSV, but possible during maternal viremia)

• Outcomes vary based on timing of infection and treatment

Neonatal Complications:

Gonorrhea:

• Ophthalmia neonatorum (most common manifestation)

• Highly contagious eye infection that can lead to blindness if untreated

• Neonatal sepsis

• Preventive erythromycin eye ointment applied to all newborns at birth

Chlamydia:

• Most common infectious cause of ophthalmia neonatorum

• >50% of exposed infants develop conjunctivitis or pneumonia

• Standard neonatal eye prophylaxis does NOT prevent perinatal chlamydial transmission

Herpes Simplex Virus (HSV):

• Neonatal herpes: 1,200-1,500 cases/year in U.S.

• ~20% mortality rate despite treatment advances

• ~20% of survivors have long-term neurologic sequelae

• Highest risk: primary maternal infection near term

• 80% of infected infants born to mothers with no known HSV history

---

Why Timing Matters

The impact depends on:

• When infection was acquired (early vs. late pregnancy)

• Presence of coinfections with other STIs

• When treatment was initiated

How does Chlamydia affect both mother and baby?

-Maternal

• Prelabor rupture of membranes

• Preterm labor

• Postpartum endometritis

-Fetal effects

• Low birth weight

How does Gonorrhea affect both mother and baby?

-Maternal

• Prelabor rupture of membranes

• Miscarriage

• Preterm labor

• Chorioammionitis

• Postpartum endometritis

• Postpartum sepsis

-Fetal effects

• Preterm birth

• Intrauterine growth restriction (IUGR)

How does Herpes simplex virus (HIV) affect both mother and baby?

-Maternal

• Intrauterine infection (rare)

-Fetal effects

• Congenital infection (rare)

How does Human papillomavirus (HPV) affect both mother and baby?

-Maternal

• Dystocia from large lesions

• Excessive bleeding from lesions after birth trauma

-Fetal effects

• None known

How does Syphilis affect both mother and baby?

-Maternal

• Miscarriage

• Preterm labor

-Fetal effects

• IUGR

• Preterm birth

• Stillbirth

• Congenital infection