OB Review #1

1. OB Review #1

2. Functions of the Female Reproductive System Produce ovum, Maintain the fertilized egg, Maintain the embryo Structures: • Ovaries: Have 2 main functions: Ovulation and production of hormones (estrogen & progesterone) • Uterus: is peared shape and measures approx 3 inches. Receives and nurtures embryo during development • Fallopian Tubes: convey ovum to uterus • Fimbrae: fingerlike projections lined by tiny hair like cilia that assist the ovum to travel to the uterus.

3. Three Phases during Menstrual Cycle • Proliferative Phase: Preparing for Ovulation - endometrium begins to grow after menstruation. • Secretory Phase: Preparing for Implantation - endometrium is becoming ready for the implantation of a blastocyst. • Menstrual Phase: If no implantation occurs, the endometrium breaks down and is discharged in menstruation.

4. Proliferation Phase: Preparing…. • Proliferation Phase starts in the anterior pituitary gland with the release of FSH (follicle stimulating hormone) • FSH goes to the ovaries and causes the ovarian graafian follicle (OVUM) to develop/mature & ripen. • Follicle begins to mature - releases ESTROGEN • Estrogen causes the uterine lining to thicken in preparation of the ovum (egg) and causes the ovum to ripen and enlarge. • When estrogen levels get high enough they cause the release of LH or luteinizing hormone

5. Premenstrual Syndrome - PMS • PMS often occurs after ovulation. • Over 150 symptoms have been reported that have been related to PMS. • Treatment includes • Counseling • Medications: NSAIDs • Dietary changes: low sodium, caffeine, chocolate. • Regular exercise: relaxation techniques

6. Candidiasis Vaginitis (yeast) • White thick curdy discharge • Vaginal itching, burning • Vaginal culture, wet mount • Treatment: vaginal creams - Minonazole, Monistat-3, Monistat-7, Nystatin • Oral – diflucan • Prevention: avoid tight fitting clothes. • Antibiotic therapy or hormonal • Yogurt • No douching

7. Ovarian Cancer • Originates in epithelial tissue of ovary. • May not produce symptoms until it is in an advanced, inoperable stage. • Survival Rate • Treatment includes a combination of surgery, radiation, chemotherapy, immunotherapy, and palliation.

8. Growth of endometrial tissue outside the uterus within the pelvic cavity. Cause is unknown Symptoms include low backache, painful intercourse, a feeling of heaviness on the pelvis, and spotting or heavy bleeding Infertility due to scar tissue Endometriosis

9. Cervical Cancer • The most preventable gynecological cancer, with regular Pap smears. • Most common signs: abnormal bleeding, odor, pain in lower back, groin, difficulty in voiding, hematuria, rectal bleeding. • Treatment includes varying degrees of surgery, radiation or radium Implants and palliation

10. Radiation Therapy/Radium Implants • May be ordered before surgical excision of the cervix • Pregnant or female nurses of childbearing age should not care for the patient or spend extended periods at the bedside. • Direct patient care should be organized. • Limit time spend at bedside • Warning Sign should be hung on the door. • Complete bed rest

11. Benign tumors growing in or on uterus. Symptoms include menorrhagia, increasing pelvic pressure, dysmenorrhea, abdominal enlargement, and constipation. Treatment: periodic reexamination, myomectomy, or hysterectomy. Fibroid Tumors

12. Downward displacement of the uterus into the vagina. Factors – multiple vaginal deliveries, large infant, Increasing age, frequent heavy lifting. A number of conditions, constipation, and obesity. Symptoms - Urinary complaints including urinary incontinence frequency, urgency, pain with defecation, constipation, or incontinence, sexual complaints, including pain with intercourse. Dx: Examination, Ultrasound, MRI Tx: kegel exercise, pessaries, surgery Prolapsed uterus

13. Uterine Prolapse Degrees • 1st degree: cervix visible at vaginal opening • 2nd degree: cervix extends beyond the vaginal opening • 3rd degree: uterus protrudes outside of the vagina.

14. Inflammation of fallopian tubes, ovaries, or both, along with vascular and supporting structures within the pelvis, except the uterus. Symptoms include fever, pelvic pain, foul-smelling vaginal discharge, pain during sexual intercourse, and nausea. Bacterial: (streptococcus, staphylococcus, gonococcus, Chlamydia Viral: Herpes simplex virus 2 Treatment: antibiotic therapy, bed rest. Hospitalization for IV medications for severe cases. Pelvic Inflammatory Disease (PID)

15. Fibrocystic Breast Disease: • Also called chronic cystic mastitis. • Symptoms include lumps that are single or multiple cysts, frequently fluid-filled. • Fibrocystic areas may mask areas of breast cancer. • BSE. • Aspiration or surgical excision may be indicated. • TX: Danazol (X) • Vitamin E • No caffeine

16. Breast Cancer Stages • 1: tumor <2cm, no lymph nodes, no metastases • 2: tumor 2 – 5cm,0-1 lymph nodes + ca, no metastases • 3: tumor >5cm, lymph nodes +ca, no metastases or tumor 0-5cm, +ca lymph nodes, no metastases • 4: tumor any size, may/may not test +ca, metastases to lungs, bone, brain, liver

17. Modified Mastectomy • A surgical procedure to remove the whole breast that has cancer, many of the nearby lymph nodes under the arm. • Chest wall muscle is not removed. • Dotted line shows entire breast and some lymph nodes are removed.

18. Lumpectomy and Partial Mastectomy • Partial Mastectomy: A surgical procedure to remove the part of the breast that contains cancer and some normal tissue around it. • Lumpectomy: A surgical procedure to remove a tumor and a small amount of normal tissue around it. • Dotted lines show area containing the tumor that is removed and some of the lymph nodes that may be removed.

19. Structural Male Disorders • Hydrocele–a benign, nontender collection of fluid within the space of the testes and the spermatic cord. • Spermatocele–benign nontender cyst of the epididymis. • Variocele–dilation of veins of the scrotum. • Torsion of the spermatic cord–twisting of the vascular pedicle of the testis.

20. Enlargement of prostate gland that occurs with aging. Treatment includes medications, balloon dilation, urethral stent, thermotherapy, and the transurethral resection (TURP). If no treatment: Infection, Renal failure and urinary obstruction Symptoms of BPH • Urgency of urination • Frequency of urination • Abdominal straining • Nocturia • Impairment of size and force of stream • Intermittent hesitancy • Incomplete bladder emptying • Terminal dribbling • Dysuria BENIGN PROSTATIC HYPERPLASIA (BPH)

21. A resectoscope inserted through the urethra, for the treatment of BPH. A wire loop cuts away prostate tissue and seals blood vessels with an electric current.

22. Assesses the patency of inflow and outflow tubing, rate of irrigation, and bladder distention by palpation. Hang irrigation solution bag no higher than 2 – 3 feet above level of the patient’s bladder. 0.9% sodium chloride solution is used for irrigation. TURP

23. Digital rectal exam: (DRE) is an exam of the rectum. A rectal exam to examine the the prostate for lumps or anything else that seems unusual. Prostate-Specific Antigen (PSA): prostate cancer screen. High PSA level: These include urinary tract infections, benign prostatic hyperplasia (BPH) and prostatitis. normal range <4 ng/ml.. Prostate Screening

24. Penile Cancer • Bacteria harbored in foreskin of uncircumcised male are irritants to glans penis and prepuce, thought to be carcinogenic. • HPV causative factor • Symptoms: itching/burning on penis, painless, nodular growth on foreskin, fatigue, weight loss. • The primary treatment is surgery. • TX: Surgical procedure, cryotherapy,radiation therapy • Prevention: Circumcision, condom use,smoking cessation.

25. Male Inflammatory disorders • Epididymitis: inflammation of epididymis. • Sterile and Nonsterile: Bilateral sterility • Untreated: necrosis, septicemia and death • Orchitis is inflammation of testes. • Bilateral: sterility • Infection or trauma • Prostatitis is inflammation of prostate. • Chlamydia or gonorrhea • Treatment for all includes antibiotics, bed rest, scrotal support, and ice to the area.

26. Process of Reproduction • Fertilization refers to the joining together of the ovum and sperm cells. • Only one sperm is required for actual fertilization. • The union between ovum and sperm occurs in the outer third of the fallopian tube. • The ovum and sperm = Zygote begins rapid cell division and in 2 to 3 days becomes a structure referred to as Morula. • The morula is a rapidly growing structure and reaches the uterus in approximately 4 days.

27. Pregnancy Test • Measure hCG (human chorionic gonadatropin) • 95-98% accuracy • blood and urine tests Estimated Date of Delivery • Nagele’s rule • Begins with 1st day of last menstrual period, subtract 3 months, and add 7 days

28. Presumptive signs and symptoms of pregnancy are those signs and symptoms that are usually noted by the patient. These signs and symptoms are not proof of pregnancy but will suspicious of pregnancy. Amenorrhea Nausea and vomiting Enlargement & Breast soreness Frequent urination Feeling tired Montgomery's tubercules Stretch marks Spider veins Quickening (fetal movement) Colostrum from breasts Presumptive Signs & Symptoms of Pregnancy

29. Quickening • This is the first perception of fetal movement within the uterus. • It usually occurs toward the end of the fifth month because of spasmodic flutter. • A multigravida can feel quickening as early as 16 weeks. • A primigravida usually cannot feel quickening until after 18 weeks.

30. Probable Signs Noted by the clinician upon examination of the patient: • Enlarged abdomen • Positive pregnancy test • Change in uterine shape • Softening of the cervix (Goodell's sign) • Chadwick’s Sign • Enlarging uterus • Braxton Hicks contractions • Hegar’s Sign • Palpation of the baby • Ballottement

31. Goodell’s Sign • Goodell’s sign • The cervix is normally firm like the cartilage at the end of the nose. The Goodell's sign is when there is marked softening of the cervix (due to invreasing vacularity and edema) • This is present at 6 weeks of pregnancy

32. Chadwick’s Sign • The vaginal walls and cervix have taken on a deeper color (blue/violet) caused by the increased vascularity because of increased hormones. • It is noted at the sixth week when associated with pregnancy. • It may also be noted with a rapidly growing uterine tumor or any cause of pelvic congestion.

33. Leopold’s Maneuvers • Series of hands on positions by examiner • Assists in determining fetal position • Performed during prenatal visits.

34. Demonstrated during the bimanual exam at the 16th to 20th week. The lower uterine segment or the cervix is tapped by the examiner's finger and left there Fetus floats upward, then sinks back and a gentle tap is felt on the finger. Ballottement

35. Braxton hicks contractions • Painless uterine contractions occurring throughout pregnancy. • May begin about the 12th week of pregnancy and becomes progressively stronger. • These contractions will, generally, cease with walking or other forms of exercise. • Are distinct from of true labor contractions by the fact that they do not cause the cervix to dilate and can usually be stopped by walking.

36. Placental Function • Transports Oxygen, nutrients, and antibodies to the fetus by means of the umbilical vein • Removes carbon dioxide and metabolic wastes from the fetus by the two umbilical arteries • Serves as a protective barrier against harmful effects of certain drugs and microorganisms • Acts as a partial barrier between the mother and fetus to prevent fetal and maternal blood from mixing • Produces hormones essential for maintaining the pregnancy. (estrogen, progesterone, and human chorionic gonadotropin (HCG)).

37. Umbilical Cord • Lifeline to mom • 2 arteries • unoxygenated blood • 1 vein • oxygenated • Wharton’s jelly • Outer covering of umbilical cord (protects cord)

38. Amnion & Chorion • Amnion: Innermost membrane that lines the amniotic space. • It is filled with fluid • At full term, this cavity normally contains 500 cc to 1000 cc of fluid (water). • Chorion: Outer membrane. • It forms a large portion of the connective tissue thickness of the placenta on its fetal side. • It is the structure in and through which the major branching umbilical vessels travel on the surface of the placenta

39. Fetal Development – fetal period 9 week - Birth • Cardiovascular • Heart begins to beat day 21 • Heart beat detectable by ultrasound at about >6 weeks • Heart beat heart at about 10 weeks by doppler • Respiratory • Surfactant matures by 36th week • Surfactant permits expansion of the lungs • GI system • Meconium (tarry stool) • Urinary system • By 5th month, fetus urinates into amniotic fluid • 2nd half of pregnancy: urine makes up major part of amniotic fluid • Sexual • Can identify male/female by 16th week

40. Age of Viability – Respiratory System • By 24 weeks the lung cells begin to produce a substance called surfactant. • Surfactant: A substance composed of lipoprotein • Secreted by the alveolar cells of the lung • Serves to maintain the stability of pulmonary tissue by reducing the surface tension of fluids that coat the lung.

41. Physiologic Anemia of Pregnancy • Blood volume increases gradually by 30 to 50% (1500 ml to 3 units). • RBC’s increase, but cannot keep up with the pace of the plasma volume • Decreased hemoglobin and hematocrit occur. • This is called pseudoanemia. • This explains why the need for iron is so important during pregnancy.

42. Respiratory System • Slight elevation in respiratory rate (18-20 in pregnancy; 12-20 is normal) • Nasal stuffiness (1st trimester) • SOB 2nd trimester • Dyspnea • Estrogen causes upper respiratory tract to become more vascular. As capillaries fill, edema develops in the nose. • Interventions: Use cool air vaporizer • NO SPRAYS • Proper position; semi-Fowlers when sleeping.

43. Musculoskeletal System • Changes in gravity • Calcium and phosphorus needs - increase • Later in pregnancy, gradual softening of pelvic ligaments and joints • Lordosis • Caused by relaxin and progesterone • Leg cramps and backache (late pregnancy) • Good nutrition, rest with legs elevated, wear warm clothing. • During leg cramp, pull toes up toward the knee/leg while pressing down on the ankle. • Use proper body mechanics; avoid high heels

44. Nausea and vomiting Gingivitis Increased saliva Constipation Increased gastric acid (heartburn/pyrosis) Causes are due to the cardiac sphincter relaxes; increased progesterone; gastric displacement; hCG levels Factors contributing to maternal nutritional needs: Inadequate nutritional intake Pica Low income Smoking, alcohol, drugs Teenagers Chronic medical conditions Short interval between pregnancies Depression Gastrointestinal System

45. Physiological changes during pregnancy • Uterus: Braxton Hicks contractions, Hegar’s sign. • Cervix: Goodell’s sign, Chadwick’s sign • Vagina: vaginal secretions prevent bacterial infections. • Breasts: Montgomery Tubercules, Colostrum

46. Psychological Adaptation to Pregnancy • Pregnancy Validation: Accepting the pregnancy • Fetal Embodiment: Body Image, baby is part of her body • Fetal Distinction: Accepting the baby • Role Transition: preparing for parenthood (The nesting stage)

47. Lightening • The descent of the presenting part of the fetus into the pelvis. Feels as if the baby is “dropping”. • Happens around the 36th week • Mucus Plug • The plug of mucus that fills the opening of the cervix • Prevents bacteria from getting into uterus

48. Identify 5 assessments of the pregnant female during return office visits • Blood Pressure • Weight total weight gain (25-35 lbs) • Week 1 - 12 = 2-4 lbs • Week 13 – 40 = 1 lb a week • Uterine Size • Edema • Fetal position (Leopold’s Maneuvers) • Fetal Heartbeat • Laboratoy test (urinalysis)

49. Spontaneous Abortions • Threatened • Inevitable • Incomplete • missed

50. Inevitable Abortion • If the treatment of threatened abortion is not adequate or timely, the abortion may become inevitable. • In this type of abortion, besides pain and bleeding there is also dilation of the cervix of the uterus and the process of expulsion of the fetus cannot be stopped.