Midwifery & Women's Health Nurse Practitioner Certification Review

MIDWIFERY & WOMEN’S HEALTH NURSE PRACTITIONER CERTIFICATION REVIEW GUIDE

Second Edition

Edited by Beth M. Kelsey, EdD, WHNP-BC Assistant Professor School of Nursing Ball State University Muncie, Indiana Board of Directors National Association of Nurse Practitioners in Women’s Health (NPWH) Washington, DC

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Library of Congress Cataloging-in-Publication Data Midwifery & women’s health nurse practitioner certification review guide / [edited by] Beth M. Kelsey.—2nd ed. â p. ; cm. â Rev. ed. of: Midwifery/women’s health nurse practitioner certification review guide. c2004. â Includes bibliographical references and index. â ISBN 978-0-7637-7417-2 (pbk.) â 1.â Nurse practitioners—Examinations, questions, etc.â 2.â Midwivesâ Examinations, questions, etc.â 3.â Gynecologic nursing—Examinations, questions, etc.â 4.â Maternity nursing—Examinations, questions, etc.â 5.â Women—Diseases— Examinations, questions, etc.â 6.â Women—Health and hygiene—Examinations, questions, etc.â I.â Kelsey, Beth.â II.â Midwifery/women’s health nurse practitioner certification review guide. â [DNLM: 1.â Midwifery—Examination Questions.â 2.â Genital Diseases, Female—nursing—Examination Questions. 3.â Nurse Midwives—Examination Questions.â 4.â Nurse Practitioners—Examination Questions.â 5.â Pregnancy Complications— nursing—Examination Questions.â 6.â Women’s Health—Examination Questions.â WY 18.2 M6288 2011] â RT82.8.M53 2011 â 610.73092—dc22 2010018003

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Printed in the United States of America 14 13 12 11 10 10 9 8 7 6 5 4 3 2 1 Contents

Prefaceâ vii Physical Examination (General Screening Examination)â 13 Contributorsâ ix Nongynecological Diagnostic Studies/ Instructions for Using the Online Access Laboratory Testsâ 19 Code Cardâ xi Health Maintenance and Risk Factor Identificationâ 22 Chapter 1 Preconception Careâ 28 Test-Taking Strategiesâ 1 Parentingâ 28 Agingâ 29 strategy #1: Know Yourselfâ 1 Pharmacologyâ 30 strategy #2: Develop Your Thinking Skillsâ 1 Questionsâ 31 strategy #3: Know the Contentâ 3 Answersâ 35 strategy #4: Become Test-Wiseâ 6 Bibliographyâ 35 strategy #5: Apply Basic Rules of Test Takingâ 7 Chapter 3 Some Dos & Don’ts to Rememberâ 8 Women’s Healthâ 37 strategy #6: Psych Yourself Up: Taking Tests is Stressfulâ 8 Beth M. Kelsey Summaryâ 9 Anne A. Moore Bibliographyâ 9 Gynecology (Normal)â 37 Chapter 2 Diagnostic Studies and Laboratory Testsâ 46 General Health Assessment and Health Fertility Controlâ 50 Promotionâ 11 Questionsâ 70 Beth M. Kelsey Answersâ 77 Bibliographyâ 78 Health Historyâ 11

iii iv Contents

Chapter 4 Primary Care of the Newborn for the First 6 Pregnancyâ 79 Weeksâ 145 Common Variations from Normal Newborn Patricia Burkhardt Findingsâ 147 Human Reproduction and Fertilizationâ 79 Deviations from Normalâ 148 Development of the Placenta, Membranes, Questionsâ 155 and Amniotic Fluidâ 80 Answersâ 160 Embryonic and Fetal Developmentâ 81 Bibliographyâ 161 Diagnosis and Dating of Pregnancyâ 82 Chapter 6 Maternal Physiologic Adaptations to Intrapartum and Postpartumâ 163 Pregnancyâ 82 Maternal Psychological/Social Changes in Susan P. âShannon Pregnancyâ 85 Overview of Antepartum Careâ 86 Initial Assessmentâ 163 Antepartum Visitâ 86 Physical Examinationâ 164 Common Discomforts of Pregnancy and Diagnostic Studiesâ 166 Comfort Measuresâ 89 Management and Teachingâ 166 Nutrition During Pregnancyâ 90 Mechanisms of Laborâ 168 The Woman and Her Family and Their Role Management of the First Stage of in Pregnancyâ 91 Laborâ 169 Teaching and Counselingâ 92 Management of the Second Stage of Pharmacologic Considerations in the Laborâ 173 Antepartum Periodâ 93 Delivery Managementâ 174 Techniques Used to Assess Fetal Healthâ 93 Management of the Third Stageâ 177 Selected Obstetrical Complicationsâ 96 Management of Immediate Newborn Medical Complicationsâ 110 Transitionâ 178 Questionsâ 120 Special Considerations and Deviations Answersâ 133 from Normalâ 178 Bibliographyâ 134 The Normal Postpartumâ 185 Assessment of Maternal Response to Chapter 5 Babyâ 186 Midwifery Care of the Newbornâ 135 Management Plan for the Postpartum Periodâ 187 Anthony A. Lathrop Postpartal Discomfortsâ 188 Physiologic Transition to Extrauterine Questionsâ 188 Lifeâ 135 Answersâ 195 Ongoing Extrauterine Transitionâ 136 Bibliographyâ 196 Immediate Care and Assessment of the Chapter 7 Healthy Newbornâ 137 Gynecological Disordersâ 197 Care During the First Hours After Birthâ 139 Penelope Morrison Bosarge Plan of Care for the First Few Days of Lifeâ 140 Menstrual and Endocrine Disordersâ 197 Discharge Planningâ 140 Benign and Malignant Tumors/ Newborn Assessmentâ 142 Neoplasmsâ 205 Contents v

Vaginal Infectionsâ 211 Answersâ 335 Sexually Transmitted Diseases (STDs)â 213 Bibliographyâ 335 Urinary Tract Disordersâ 222 Breast Disordersâ 224 Chapter 9 Congenital and Chromosomal Advanced Practice Nursing and Abnormalitiesâ 227 Midwifery: Role Development, Trends, Additional Gynecological Disordersâ 228 and Issuesâ 337 Questionsâ 236 Patricia Burkhardt Answersâ 242 Bibliographyâ 243 Advanced Practice Registered Nurse (APRN)â 337 Chapter 8 Midwiferyâ 339 Nongynecological Disorders/ Trends and Issuesâ 341 Problemsâ 245 Professional Components of Advanced Practice Nursing and Midwiferyâ 344 Sandra K. Pfantz Health Policy and Legislative Regulation of Beth M. Kelsey Midwifery and Nursingâ 346 Mary C. Knutson Healthcare Delivery Systemsâ 346 Cardiovascular Disordersâ 245 Ethical and Legal Issues and Eye, Ear, Nose, and Throat Disordersâ 255 Principlesâ 349 Lower Respiratory Disordersâ 264 Health Insurance Portability and Gastrointestinal Disordersâ 269 Accountability Act of 1996 (HIPAA)— Hematologic Disordersâ 282 Public Law 104–191â 350 Immunologic Disordersâ 286 Evidence-Based Practiceâ 352 Endocrine Disordersâ 293 Questionsâ 352 Musculoskeletal Disordersâ 301 Answersâ 356 Neurologic Disordersâ 307 Bibliographyâ 356 Dermatologic Disordersâ 313 Psychosocial Problemsâ 318 Indexâ 359 Questionsâ 325

Preface

A comprehensive review essential for those preparing guide is to provide a succinct, yet comprehensive to take the midwifery (AMBC) or women’s health nurse review of the core material. practitioner certification (NCC) examinations. The The book has been organized to provide the reader Midwifery & Women’s Health Nurse Practitioner Certi- with test-taking and study strategies first. This is an fication Review Guide was developed for both of these imperative prerequisite for success in the certification nursing specialties because of the many commonalities examination arena. they share that enhance the delivery of care to women This chapter is followed by chapters on General during their life span. Experts in the field of women’s Health Assessment and Health Promotion, Women’s health as well as midwifery combined their expertise Health, Pregnancy, Midwifery Care of Newborn, Intra- and wisdom to provide an invaluable resource that partum and Postpartum, Gynecological Disorders/ will not only assist women’s health nurse practitio- Problems, and Nongynecological Disorders. The final ners and midwives in their pursuit of success on their chapter addresses professional issues that directly respective certification examinations, but assist them impact the midwife and nurse practitioner, including in their delivery of care in the practice setting. In addi- nursing research, roles, ethical issues, health policy/ tion, multiple resources have been utilized to ensure legislative issues, and legal aspects of practice. the integrity of this text so that it is representative of the Following each chapter are test questions, which kinds of questions that may be encountered by both are intended to serve as an introduction to the testing specialties during the examination process. arena. These questions are representative of those Although the birthing process itself may not fall found on the examinations. A bibliography is included within the realm of the women’s health nurse practi- at the completion of each chapter for those who need a tioner practice, the knowledge of the process will add more in depth discussion of the subject matter. a valuable component which can only improve the The editor and contributing authors are certified quality of the care provided by the nurse practitioner. nurse practitioners and certified nurse midwives. They An acute awareness of the childbearing process and its have designed this book to assist potential examinees implications throughout a woman’s life span can only to prepare for success in the certification examination improve the outcome of care delivered. process as well as improve the examinee’s knowledge in Many nurses preparing for certification examina- the practice setting. tions find that reviewing an extensive body of scien- It is assumed that the reader of this review guide has tific knowledge requires a very difficult search of many completed a course of study in either a women’s health sources that must be synthesized to provide a review nurse practitioner or midwifery program. It is not base for the examination. The purpose of this review intended to be a basic learning tool.

vii

Front/EndContributors Matter Title

Penelope Morrison Bosarge, MSN, RNC, WHNP Anthony A. Lathrop, MSN, CNM, RDMS Women’s Health Nurse Practitioner Perinatal Nurse–Midwife Coordinator Women’s Health Care Nurse Practitioner Maternal–Fetal Medicine Program Northern Illinois Regional Perinatal Center University of Alabama, Birmingham Rockford Memorial Hospital School of Nursing Rockford, Illinois Birmingham, Alabama Anne A. Moore, MSN, RNC, WHNP, FAANP Patricia Burkhardt, DrPH, CNM Women’s Health Nurse Practitioner Nurse Midwife Professor Associate Clinical Professor School of Nursing Midwifery Program Vanderbilt University Division of Nursing Nashville, Tennessee New York University New York, New York Sandra K. Pfantz, DrPH, APRN Adult Nurse Practitioner Beth M. Kelsey, EdD, WHNP-BC Associate Professor Women’s Health Nurse Practitioner School of Nursing Assistant Professor St. Xavier University School of Nursing Department of Family Medicine Ball State University University of Illinois at Chicago Muncie, Indiana Chicago, Illinois

Mary C. Knutson, MN, RNC, ANP Susan P. Shannon, MS, CNM, RNC Adult Nurse Practitioner Nurse Midwife Nurse Consultant Director, Women’s and Infant Services Alaska Department Health & Social Services Sharon Hospital Anchorage, Alaska Sharon, Connecticut California State University, Los Angeles

Instructions for Using the Online Access Code Card

Enclosed within this review guide you will find a printed “access code card” containing an access code providing you access to the new online interactive testing program, JB TestPrep. This program will help you prepare for certification exams, such as the American Nurse Credentialing Center’s (ANCC’s) certification exam to become a certified nurse practitioner. The online program includes the same multiple choice questions that are printed in this study guide. You can choose a “practice exam” that allows you to see feedback on your response immediately, or a “final exam,” which hides your results until you have completed all the questions in the exam. Your overall score on the questions you have answered is also compiled. Here are the instructions on how to access JB TestPrep, the Online Interactive Testing Program:

1.â Find the printed access code card bound in to this book. 2.â Go to www.JBLearning.com/usecode. 3.âEnter in your 10-digit access code, which you can find by scratching off the protective coating on the access code card. 4.âFollow the instructions on each screen to set up your account profile and password. Please note: Only select a course coordinator if you have been instructed to do so by an institution or an instructor. 5.âContact Jones & Bartlett Learning technical support if you have any questions: Call 800-832-0034 Visit www.jblearning.com and select “Tech Support” Email [email protected]

1 Test-Taking Strategies and Techniques

We all respond to testing situations in different ways. of thinking as well as the techniques to enhance the What separates the successful test taker from the un- thought process. Everyone has a personal learning successful one is knowing how to prepare for and take a style, but we all must proceed through the same pro- test. Preparing yourself to be a successful test taker is as cess to think. important as studying for the test. Each person needs Thinking occurs on two levels––the lower level of to assess and develop their own test-taking strategies memory and comprehension and the higher level of ap- and skills. The primary goal of this chapter is to assist plication and analysis (ABP, 1989). Memory is the abil- potential examinees in knowing how to study for and ity to recall facts. Without adequate retrieval of facts, take a test. progression through the higher levels of thinking cannot occur easily. Comprehension is the ability to understand memorized facts. To be effective, comprehension ¶ STRATEGY #1: KNOW YOURSELF skills must allow the person to translate recalled information from one context to another. Application, or the When faced with an examination, do you feel threat- process of using information to know why it occurs, is ened, experience butterflies or sweaty palms, or have a higher form of learning. Effective application relies trouble keeping your mind focused on studying or on on the use of understood memorized facts to verify in- the test questions? These common symptoms of test tended action. Analysis is the ability to use abstract or anxiety plague many of us, but can be used advanta- logical forms of thought to show relationships and to geously if understood and handled correctly (Divine distinguish the cause and effect between the variables & Kylen, 1979). Over the years of test taking, each of in a situation. us has developed certain testing behaviors, some of As applied to testing situations, the thought pro- which are beneficial, while others present obstacles to cess from memory to analysis occurs quite quickly. successful test taking. You can take control of the test- Some examination items are designed to test memory taking situation by identifying the undesirable behav- and comprehension, while others test application iors, maintaining the desirable ones, and developing and analysis. An example of a memory question is as skills to improve test performance. follows:

¶ STRATEGY #2: DEVELOP YOUR Clients’ initial response to learning that they have a THINKING SKILLS terminal illness is generally: Understanding Thought Processes a) Depression b) Bargaining In order to improve your thinking skills and subsequent c) Denial test performance, it is best to understand the types d) Anger

1 2 Chapter 1 Test-Taking Strategies and Techniques

To answer this question correctly, the individual has Building Your Thinking Skills to retrieve a memorized fact. Understanding the fact, knowing why it is important or analyzing what should Effective memorization is the cornerstone to learning be done in this situation is not needed. An example of a and building thinking skills (Olney, 1989). We have all question that tests comprehension is as follows: experienced “memory power outages” at some time, due in part to trying to memorize too much, too fast, Shortly after having been informed that she is in the too ineffectively. Developing skills to improve memo- terminal stages of breast cancer, Mrs. Jones begins to rization is important to increasing the effectiveness of talk about her plans to travel with her husband when your thinking and subsequent test performance. he retires in two years. The nurse should know that: a) The diagnosis could be wrong and Mrs. Jones may Technique #1 not be dying. Quantity is not quality, so concentrate on learning im- b) Mrs. Jones is probably responding to the news by portant content. For example, it is important to know using the defense mechanism of denial. the various pharmacologic agents appropriate for the c) Mrs. Jones is clearly delusional. management of chronic obstructive pulmonary disease d) Mrs. Jones is not responding in the way most cli- (COPD), not the specific dosages for each medication. ents would. Technique #2 In order to answer this question correctly, an individual must retrieve the fact that denial is often the first Memory from repetition, or saying something over and response to learning about a terminal illness and that over again to remember it usually fades. Developing Mrs. Jones’ behavior is indicative of denial. memory skills that trigger retrieval of needed facts is In a higher level of thinking examination question, more useful. Such skills are as follows: individuals must be able to recall a fact, understand Acronyms that fact in the context of the question and apply this These are mental crutches that facilitate recall. Some understanding to explaining why one answer is correct are already established such as PERRL (pupils equal, after analyzing the answer choices as they relate to the round, reactive to light), or PAT (paroxysmal atrial situation (Sides & Cailles, 1989). An example of an ap- tachycardia). Developing your own acronyms can be plication analysis question is as follows: particularly useful since they are your own word associ- Mr. Smith has just learned that he has an inoperable ation arrangements in a singular word. Nonsense words brain tumor. His comment when the nurse speaks to or funny, unusual ones are often more useful since they him later is, “This can’t possibly be true. Mistakes are attract your attention. made in hospitals all the time. They might have mixed Acrostics up my test results.” The nurse’s most appropriate re- This mental tool arranges words into catchy phrases. sponse would be to: The first letter of each word stands for something that a) Refer Mr. Smith for a psychiatric consultation is recalled as the phrase is said. Your own acrostics are b) Neither agree nor disagree with Mr. Smith’s most valuable in triggering recall of learned informa- comment tion since they are your individual situation associa- c) Confront Mr. Smith with his denial tions. An example of an acrostic is as follows: d) Agree with Mr. Smith that mistakes can happen Kissing Patty Produces Affection stands for the and tell him you will see about getting repeat four types of nonverbal messages: Kinesics, Para- tests language, Proxemics, and Appearance. To answer this question correctly, the individual must ABCs recall the fact that denial is often the initial response to This technique facilitates information retrieval by using learning about a terminal illness; understand that Mr. the alphabet as a crutch. Each letter stands for a symp- Smith’s response in this case is evidence of the normal tom, which when put together creates a picture of the use of denial; apply this knowledge to each option, un- clinical presentation of the disease. For example, the derstanding why it may or may not be correct; and ana- characteristics of the disease and symptoms of osteoar- lyze each option for what action is most appropriate for thritis using the ABC technique are as follows: this situation. Application/analysis questions require the examinee to use logical rationale, which demon- a) Aching or pain strates the ability to analyze a relationship, based on b) Being stiff on awakening a well-defined principle or fact. Problem-solving abil- c) Crepitus ity becomes important as the examinee must think d) Deterioration of articular cartilage through each question option, deciding its relevance e) Enlargements of distal interphalangeal joints and importance to the situation of the question. f) Formation of new bone at joint surface Strategy #3: Know the Content 3

g) Granulation inflammatory tissue Words that rhyme can also be used to jog the mem- h) Heberden’s nodes ory about important characteristics of phenomena. For example, the stages of group therapy can be remem- One Letter bered and characterized by the following, according to Recall is enhanced by emphasizing a single letter. The Tuckman (1965): major symptoms of schizophrenia are often remembered as follows: Forming Storming Affect (flat) Norming Autism Performing Auditory hallucinations Setting content to music is sometimes useful for re- Imaging membering. Melodies that are repetitious jog the mem- This technique can be used in two ways. The first is ory by the ups and downs of the notes and the rhythm to develop a nickname for a clinical problem that of the music. when said produces a mental picture. For example, Links connect key words from the content by using “a wan, wheezy pursed lip” might be used to visual- them in a story. An example given by Olney (1989) for ize a patient with pulmonary emphysema who is thin, remembering the parts of an eye is: IRIS watched a PU- emaciated, experiencing dyspnea, with a hyperin- PIL through the LENS of a RED TIN telescope while eat- flated chest, who has an elongated expiratory breathing CORN-EA on the cob. ing phase. A second form of imaging is to visualize a Additional memory aids may also include the use specific patient while you are trying to understand or of color or drawing for improving recall. Use different solve a clinical problem when studying or answering colored pens or paper to accentuate the material being a question. For example, imagine an elderly man who learned. For example, highlight or make notes in blue is experiencing an acute asthma attack. You are trying for content about respiratory problems and in red for to analyze the situation and place him in a position cardiovascular content. Drawing assists with visualiz- that maximizes respiratory effort. In your mind you vi- ing content as well. This is particularly helpful for re- sualize him in various positions of side lying, angular membering the pathophysiology of the specific health and forward, imaging what will happen to the man in problem. each position. A second form of imaging is to visual- The important thing to remember about remem- ize a specific situation while you are trying to answer bering is to use good recall techniques. a question. For example, if you are trying to remember how to describe active listening or physical attend- Technique #3 ing skills, see yourself in a comfortable environment, Improving higher-level thinking skills involves exer- facing the other person, with open posture and eye cising the application and analysis of memorized fact. contact. Small group review is particularly useful for enhancing Rhymes, Music, and Links these high level skills. It allows verbalization of thought The absurd is easier to remember than the most com- processes and receipt of input about content and mon. Rhymes, music, or links can add absurdity and thought process from others (Sides & Cailles, 1989). humor to learning and remembering (Olney, 1989). Individuals not only hear how they think, but how oth- These retrieval tools are developed by the individual ers think as well. This interaction allows individuals for specific content. For example, making up a rhyme to identify flaws in their thought process as well as to about diabetes may be helpful in remembering the pre- strengthen their positive points. dominant female incidence, origin of disease, primary Taking practice tests is also helpful in developing symptoms, and management, as illustrated by: application/analysis thinking skills. These tests permit the individual to analyze thinking patterns as well as There once was a woman the cause-and-effect relationships between the ques- whose beta cells failed. tion and its options. The problem-solving skills needed She grew quite thirsty to answer application/analysis questions are tested, and her glucose levels sailed. giving the individual more experience through practice Her lack of insulin caused her to (Dickenson-Hazard, 1990). increase her intake, And her increased urinary output Â STRATEGY #3: Know the Content was certainly not fake. So she learned to watch her diet Your ability to study is directly influenced by organiza- and administer injections tion and concentration (Dickenson-Hazard, 1990). If That kept her healthy, happy effort is spent on both of these aspects of exam prepa- and free of complications. ration, examination success can be increased. 4 Chapter 1 Test-Taking Strategies and Techniques

Preparation for Studying: Getting Â Table 1-1â Sample Content Assessment Organized Exam Content: Theories & Skills Study habits are developed early in our educational Rating: experiences. Some of our habits enhance learning, al- Category: Provided Provided by though others do not. To increase study effectiveness, by Test Giver Examinee organization of study materials and time is essential. Group dynamics 2 Organization decreases frustration, allows for easy re- Group process 2 sumption of study, and increases concentrated study time. Behavior modification 3 Crisis intervention 1 Technique #1 Reality therapy 4 Create your own study space. Select a study area that Communication process 3 is yours alone, free from distractions, comfortable and Interviewing skills 3 well lighted. The ventilation and room temperature Self-care 4 should be comfortable since a cold room makes it difficult to concentrate and a warm room may make you Decision making 1 sleepy (Burkle & Marshak, 1989). All your study materi- Legal/ethical issues 2 als should be left in your study space. The basic premise Cognitive techniques 2 of a study space is that it facilitates a mind set that you Mental status evaluation 3 are there to study. When you interrupt study, it is best to leave your materials just as they are. Do not close books Problem solving 3 or put away notes as you will just have to relocate them, Community resources evaluation 3 wasting your study time, when you do resume study. Nursing process 3 Nursing theory 2 Technique #2 Role theory 3 Define and organize the content. From the test giver, se- Change theory 2 cure an outline or the content parameters that are to be examined. If the test giver’s outline is sketchy, develop a Communication theories 2 more detailed one for yourself using the recommended Organizational theory 2 text as a guideline. Next, identify your available study Research design 2 resources: class notes, old exams, handouts, textbooks, Research evaluation 2 review courses, or study groups. For national standardized exams, such as initial licensing or certification, it Research application 2 is best to identify one or two study resources that cover Team building 3 the content being tested and stick to them. Attempt- Conflict management 2 ing to review all available resources is not only mind Teaching/learning skills 3 boggling, but increases anxiety and frustration as well. Supervisory skills 3 Make your selections and stay with them. Observation skills 3 Technique #3 Evaluation skills 2 Conduct a content assessment. Use a simple rating Nursing diagnosis 3 scale such as the following: DSM IV 3 1 = requires no review Grief and loss theory 3 2 = requires minimal review Death and dying 2 3 = requires intensive review Stress management theory 2 4 = start from the beginning Stress management skills 4 Read through the content outline and rate each con- Family dynamics 2 tent area (Dickenson-Hazard, 1990). Table 1-1 provides Assertiveness training skills 3 a sample exam content assessment. Be honest with Motivation skills 4 your assessment. It is far better to recognize your content weaknesses when you can study and remedy them, Houseman, C. (Ed.). (1998). Psychiatric certification review guide for rather than thinking during the exam how you wished the generalist and clinical specialist in adult, child, and adolescent you had studied more. Likewise with content strengths: psychiatric and mental health nursing (2nd ed.). Sudbury, MA: if you know the material, do not waste time studying it. Jones and Bartlett. Strategy #3: Know the Content 5

Â Table 1-2â Sample Study Plan

Goal: Achieve a passing grade on the certification exam. Time available: 2 Months Objective Activity Date Accomplished Understand elements of milieu Read section in Chapter 2 Feb. 5 & 6, 1 hour each day therapy Read notes from review class and combine Feb. 7, 1 hour with notes taken from text Review combined notes and sample test Feb. 8, 1 hour questions Master social/cultural/ethnic Read section in Chapter 2—take notes on Feb. 9 & 10, 1 hour each day factors chapter content Read notes from review class and combine Feb. 11, 1 hour with notes taken from text Review combined notes and sample test Feb. 12, 1 hour questions

Know material contained in Read ANA Publication—Take notes on Feb. 13 & 14, 1 hour each day Code for Nurses with Interpretive content Statements

Houseman, C. (Ed.). (1998). Psychiatric certification review guide for the generalist and clinical specialist in adult, child, and adolescent psychiatric and mental health nursing (2nd ed.). Sudbury, MA: Jones and Bartlett.

Technique #4 your peak study times and using techniques to maxi- Develop a study plan. Coordinate the content that mize them. needs to be studied with the time available (Sides & Technique #1 Cailles, 1989). Prioritize your study needs, starting with weak areas first. Allow for a general review at the end Study in short bursts. Each of us have our own biologic of the study plan. Lastly, establish an overall goal for clock that dictates when we are at our peak during yourself––something that will motivate you when it is the day. If you are a morning person, you are gener- brought to mind. ally active and alert early in the day, slowing down and Table 1-2 illustrates a study plan developed on the ba- becoming drowsy by evening. If you are an evening per- sis of the exam content assessment in Table 1-1. Con- son, you do not completely wake up until late morning ducting an assessment and developing a study plan and hit your peak in the afternoon and evening. Each should require no more than 50 minutes. It is a wise person generally has several peaks during the day. It is investment of time with potential payoffs of reduced best to study during those times when your alertness is study stress and enhanced exam success. at its peak (Dickenson-Hazard, 1990). During our concentration peaks, there are mini- Technique #5 peaks, or bursts of alertness (Olney, 1989). These alert- Begin now and use your time wisely. The smart test ness peaks of a concentration peak occur because levels taker begins the study process early (Olney, 1989). Sit of concentration are at their highest during the first part down, conduct the content assessment and develop a and last part of a study period. These bursts can vary study plan as soon as you know about the exam. Do not from 10 minutes to 1 hour depending on the extent of procrastinate! concentration. If studying is sustained for 1 hour there are only two mini peaks; one at the beginning and one at the end. There are eight mini-peaks if that same hour Getting Down To Business: is divided into 4, 10-minute intervals. Hence it is more The Actual Studying helpful to study in short bursts (Olney, 1989). More can be learned in less time. There is no better way to prepare for an examination than individual study (Dickenson-Hazard, 1989). The Technique #2 responsibility to achieve the goal you set for this exam Cramming can be useful. Since concentration ability lies with you alone. The means you employ to achieve is highly variable, some individuals can sustain their this goal do vary and should begin with identifying mini-peaks for 15, 20, or even 30 minutes at a time. 6 Chapter 1 Test-Taking Strategies and Techniques

Pushing your concentration beyond its peak is fruitless helpful. Ways to be active include: taking notes on the and verges on cramming, which in general is a poor content as you study; constructing questions and an- study technique. There are, however, times when cram- swering them; taking practice tests; or discussing the ming, a short-term memory tool, is useful. Short-term content with yourself. Also, using your individual study memory generally is at its best in the morning. A quick quirks is encouraged. Some people stand, others walk review or cram of content in the morning can be useful around and some play background music. Whatever the day of the exam (Olney, 1989). Most studying, how- helps you to concentrate and study better, you should ever, is best accomplished in the afternoon or evening use. when long-term memory functions at its peak. Technique #8 Technique #3 Use study aids. Although there is no substitute for in- Give your brain breaks. Regular times during study to dividual studying, several resources, if available, are rest and absorb the content are needed by the brain. useful in facilitating learning. Review courses are an The best approach to breaks is to plan them and give excellent means for organizing or summarizing your yourself a conscious break (Dickenson-Hazard, 1990). individual study. They generally provide the content This approach eliminates the “day dreaming” or “wan- parameters and the major concepts of the content that dering thought” approach to breaks that many of us you need to know. Review courses also provide an op- use. It is better to get up, leave the study area and do portunity to clarify not-well-understood content, as something non-study related for longer breaks. For well as to review known material (Dickenson-Hazard, shorter breaks of 5 minutes or so, leave your desk, gaze 1990). Study guides are useful for organizing study. out the window or do some stretching exercises. When They provide detail on the content that is important your brain says to give it a rest, accommodate it! You to the exam. Study groups are an excellent resource for will learn more with less stress. summarizing and refining content. They provide an opportunity for thinking through your knowledge base, Technique #4 with the advantage of hearing another person’s point of Study the correct content. It is easy for all of us to be- view. Each of these study aids increases understanding come bogged down in the detail of the content we are of content and when used correctly, increases effective- studying. However, it is best to focus on the major con- ness of knowledge application. cepts or the “state of the art” content. Leave the details, the suppositions and the experience at the door of your Technique #9 study area. Concentrate on the major textbook facts Know when to quit. It is best to stop studying when and concepts that revolve around the subject matter your concentration ebbs. It is unproductive and frus- being tested. trating to force yourself to study. It is far better to rest or Technique #5 unwind, then resume at a later point in the day. Avoid studying outside your morning or afternoon concen- Fit your studying to the test type. The best way to pre- tration peaks and focus your study energy on your right pare for an objective test is to study facts, particularly time of day or evening. anything printed in italics or bold. Memory enhancing techniques are particularly useful when preparing for an objective test. If preparing for an essay test, study Â STRATEGY #4: Become Test-Wise generalities, examples, and concepts. Application techniques are helpful when studying for this type of an Most nursing examinations are composed of multiple- exam (Burkle & Marshak, 1989). choice questions (MCQs). This type of question requires the examinee to select the best response(s) for Technique #6 a specific circumstance or condition. Successful test Use your study plan wisely. Your study plan is meant taking is dependent not only on content knowledge to be a guide, not a rigid schedule. You should take but on test-taking skill as well. If you are unable to im- your time with studying. Do not rush through the con- part your knowledge through the vehicle used for its tent just to remain on schedule. Occasionally study conveyance, i.e., the MCQ, your test-taking success is plans need revision. If you take more or less time than in jeopardy. planned, readjust the plan for the time gained or lost. The plan can guide you, but you must go at your own Technique #1 pace. Recognize the purpose of a test question. Most test questions are developed to examine knowledge at two Technique #7 separate levels: memory and application. A memory Actively study. Being an active participant in study question requires the examinee to recall and com- rather than trying to absorb the printed word is also prehend facts from their knowledge base while an Strategy #5: Apply Basic Rules of Test Taking 7 application question requires the examinee to use and Technique #4 apply the knowledge (ABP, 1989). Memory questions Practice, practice, practice. Taking practice tests can test recall, but application questions test synthesis and improve performance. Although they can assist in eval- problem-solving skills. When taking a test you need to uation of your knowledge, their primary benefit is to be aware of whether you are being asked a fact or to use assist you with test-taking skills. You should use them that fact. to evaluate your thinking process, your ability to read, understand and interpret questions, and your skills in Technique #2 completing the mechanics of the test. Recognize the components of a test question. Multiple Exam resources, including sample questions for the choice questions may include the basic components of American Nurses Credentialing Center (ANCC) cer- a background statement, a stem and a list of options. tification exams, are available online at: http://www. The background statement presents information that nursecredentialing.org/Certification/ExamResources.aspx. facilitates the examinee in answering the question. The stem asks or states the intent of the question. The options are four to five possible responses to the question. Â STRATEGY #5: Apply Basic Rules The correct option is called the keyed response and all of Test Taking other options are called distractors (ABP, 1989). Know- Technique #1 ing the components of a test question helps you sift through the information presented and focus on the Follow your regular routine the night before a test. Eat question’s intent (see Table 1-3). familiar foods. Avoid the temptation to cram all night. Go to bed at your regular time (Nugent and Vitale, Technique #3 1997). Recognize the item types. Basically two styles of MCQs are used for examinations. One requires the examinee Technique #2 to select the one best answer; the other requires selection of multiple correct answers. Among the one- Be prepared for exam day. It is important to familiarize best-answer styles there are three types. The A type yourself with the test site, the building, the parking, and requires the selection of the best response among travel route prior to the exam day. If you must travel, those offered. The B type requires the examinee to arrive early to allow time for this familiarization. It is match the options with the appropriate statement. helpful to make a list of things you need on the exam The X type asks the examinee to respond either true day: pencils, admission card, watch, and a few pieces or false to each option (ABP, 1989). Most standardized of hard candy as a quick energy source. On exam day tests, such as those used for nursing licensure and allow yourself plenty of time to arrive at the site. Wear certification, are composed of four or five option-A comfortable clothes and have a good breakfast that type questions. morning.

Â Table 1-3â Anatomy of a Test Question

Background statement A woman brings her 65-year old mother in to see a clinical nurse specialist because she is concerned that it is now a month since her mother was widowed, and she continues to be tearful when talking about the loss and wants to visit the grave regularly. Stem Which of the following initial approaches would most likely result in compliance with your nursing recommendations? Options a. Three or four short questions followed by a request to a psychiatrist to prescribe an antidepressant b. Immediate reassurance only c. Careful listening and open-ended questions d. Referring the mother to a support group

Technique #3 Considerations for computerized examinations: Understand all the directions for the test. Know if the test has a penalty for guessing or if you should attempt All ANCC certification examinations are computer- every question (Nugent and Vitale, 1997). based exams. • Be sure that you have completed all information Technique #4 needed to register for the exam. • Bring a photo ID—If a letter of authorization is Read the directions carefully. An exam may have sev- needed, have it with you. eral types of questions. Be on the lookout for changing • If you are easily distracted by sound, consider us- item types and be sure you understand the directions ing earplugs (these may be available at the testing on how you are to answer before you begin reading the center; check before using your own). question. • Personal items such as books, laptop computers, iPods, cellular telephones, food or drink are not al- Technique #5 lowed during testing, secure these items elsewhere. Use time wisely and effectively. Allow no more than 1 • Arrive 30 minutes before the appointed testing minute per question. Skip difficult questions and re- time. turn to them later or make an educated guess. • If you are not comfortable taking exams using a computer, consider taking a practice exam usually Technique #6 available at the examination site. • Use computer-based practice exams, particularly if Read and consider all options. Be systematic and use you are unfamiliar with this testing format. Sample problem-solving techniques. Relate options to the online questions for each ANCC certification exam question and balance them against each other. are available at: http://www.nursecredentialing. org/Certification/ExamResources.aspx. Technique #7 • Know what to do if you experience any electronic or other difficulties during the examination. In ad- Check your answers. Reconsider your answers, espe- dition to addressing the issue at the test site, you cially those in which you made an educated guess. You should also notify the certifying board (inform may have gained information from subsequent ques- ANCC about problems during exam using the post- tions that is helpful in answering previous questions or test survey). may be less anxious and more objective by the end of the test. Â STRATEGY #6: Psych Yourself Up: Taking TestS is Stressful Â Some Dos & Don’ts to Remember Although a little stress can be productive, too much can incapacitate you in your studying and test taking • Do identify key words in the stem before looking at (Divine & Kylen, 1979). For persons with severe test options. anxiety, interventions such as cognitive therapy, sys- • Do confine your thinking to the information tematic desensitization, study skills counseling and provided. biofeedback have all been used with some success • Do eliminate wrong answers and focus on the one (Spielberger, 1995). Techniques derived from these ap- or two most likely correct responses. proaches can influence the results achieved by chang- • Do guess; generally there is no penalty (loss of extra ing attitudes and approaches to test taking and thereby points) for having done so—true for ANCC exams. reducing anxiety. Psyching yourself up can have a posi- • Don’t spend too much time on any one question— tive effect and make examinations a nonanxiety-laden it is a timed examination. experience (Dickenson-Hazard, 1990). The following • Don’t second-guess—your first response is likely techniques are based on the principles of successful the best response. test taking as presented by Sides & Cailles (1989). In- • If you tend to second-guess your responses, only corporation of these techniques can improve response review questions that you could not answer on and performance in examination situations. the first pass through the exam—computer- based exams allow you to mark questions that Technique #1 you may want to address later in the exam. • Don’t change an answer without a good reason, Adopt an “I can” attitude. Believing you can succeed such as having misread the question. is the key to success. Self-belief inspires and gives you Bibliography 9 the power to achieve your goals. Without a success atti- is not the end of the world unless you allow it to be. It is tude, the road to your goal is much harder. We all stand best to deal with the failure and move on, otherwise it an equal chance of success in this world. It is those interferes with your success. who believe they can who achieve it. This “I can” attitude must permeate all your efforts in test taking, from Technique #8 studying to improving your skills, to actually writing the test. Persevere, persevere, persevere! Endurance must un- derlie all your efforts. Call forth those reserve energies Technique #2 when you have had all you think you can take. Rely upon yourself and your support systems to help you Take control. By identifying your goal, deciding how to maintain a sense of direction and keep your goal in the accomplish it and developing a plan for achieving it, forefront. you take control. Do not leave your success to chance; control it through action and attitude. Technique #9

Technique #3 Motivation is muscle. Most individuals are motivated by fear or desire. The fear in an exam situation may be Think positively. Examinations are generally based on one of failure, the unknown or discovery of imperfec- a standard that is the same for all individuals. Every- tion. Put your fear into perspective; realize you are not one can potentially pass. Performance is influenced the only one with fear and that all have an equal oppor- not only by knowledge and skill but by attitude as well. tunity for success. Develop strategies to reduce fear and Those individuals who regard an exam as an opportu- use fear to your advantage by improving the imperfec- nity or challenge will be more successful. tions. Desire is a powerful motivator, and you should keep the rewards of your desire foremost in your mind. Technique #4 Whatever motivates you, use it to make you successful. Reward yourself during your exam preparation and Project a positive self-fulfilling prophecy. While prepar- once the exam has been completed. You alone hold the ing for an examination, project thoughts of the posi- key to success; use what you have wisely. tive outcomes you will experience when you succeed. Self-talk is self-fulfilling. Expect success, not failure, for Â SUMMARY yourself. This chapter has provided concepts, strategies and Technique #5 techniques for improving study and test-taking skills. Your first task in improvement is to know yourself: how Feel good about yourself. Without feeling a sense of you study and how you take a test. You should use your positive self-worth, passing an examination is difficult. strengths and remedy the weaknesses. Next you need Recognize your professional contributions and give to develop your thinking skills. Work on techniques yourself credit for your accomplishments. Think “I will to improve memory and reasoning. Now you need to pass,” not “I suppose I can.” organize your study and concentrate on using your strengths and these new and improved skills to be suc- Technique #6 cessful. Create a study space, develop a plan of action, then implement that plan during your periods of peak Know yourself. Focus exam preparation and test taking concentration. Before taking the exam, be sure you un- on your strengths. Try to alter your weaknesses instead derstand the components of a test question, can iden- of becoming hung up on them. If you tend to overana- tify key words and phrases and have practiced. Apply lyze, study and read test questions at face value. If you the test-taking rules during the exam process. Finally, are a speed demon when taking a test, slow down and believe in yourself, your knowledge, and your talent. read more carefully. Believing you can accomplish your goal facilitates the fact that you will. Technique #7 Â Bibliography Failure is a possibility. We all have failed at something at some point in our lives. Rather than dwelling on the American Board of Pediatrics. (1989). Developing ques- failure, making excuses and believing you will fail again, tions and critiques. Unpublished material. recognize your mistakes and remedy them. Failure is a Burke, M. M., & Walsh, M. B. (1992). Gerontologic nurs- time to begin again; use it as a motivator to do better. It ing. St. Louis: Mosby Year Book. 10 Chapter 1 Test-Taking Strategies and Techniques

Burkle, C. A., & Marshak, D. (1989). Study program: Millonig, V. L. (Ed.). (1994). The adult nurse practitio- Level 1. Reston, VA: National Association of Second- ner certification review guide (rev. ed). Potomac, MD: ary School Principals. Health Leadership Associates. Conaway, D. C., Miller, M. D., & West, G. R. (1988). Geri- Nugent, P. M., & Vitale, B. A. (1997). Test success: Test- atrics. St. Louis: Mosby Year Book. taking techniques for beginning nursing students. Dickenson-Hazard, N. (1989). Making the grade as a Philadelphia, PA: F. A. Davis Co. test taker. Pediatric Nursing, 15, 302–304. Olney, C. W. (1989). Where there’s a will, there’s an A. Dickenson-Hazard, N. (1989). Anatomy of a test ques- New Jersey: Chesterbrook Educational Publishers. tion. Pediatric Nursing, 15, 395–399. Sides, M., & Cailles, N. B. (1989). Nurse’s guide to suc- Dickenson-Hazard, N. (1990). The psychology of successful test taking. Philadelphia, PA: J. B. Lippincott cessful test taking. Pediatric Nursing, 16, 66–67. Co. Dickenson-Hazard, N. (1990). Study smart. Pediatric Sides, M., & Korchek, N. (1998). Nurse’s guide to success- Nursing, 16, 314–316. ful test taking: Learning strategies for nurses (3rd ed.). Dickenson-Hazard, N. (1990). Study effectiveness: Are Philadelphia, PA: Lippincott-Raven. you 10 a.m. or p.m. scholar? Pediatric Nursing, 16, Sides, M., & Korchek, N. (1994). Nurse’s guide to suc- 419–420. cessful test taking (2nd ed.). Philadelphia, PA: J. B. Dickenson-Hazard, N. (1990). Develop your thinking Lippincott. skills for improved test taking. Pediatric Nursing, 16, Spielberger, C. D., & Vagg, P. R. (1995). Test anxiety: The- 480–481. ory, assessment, and treatment. Washington, DC: Tay- Divine, J. H., & Kylen, D. W. (1979). How to beat test anx- lor and Francis. iety. New York: Barrons Educational Series, Inc. Millman, J., & Pauk, W. (1969). How to take tests. New York: McGraw-Hill Book Co. 2 General Health Assessment and Health Promotion

Beth M. Kelsey

¶ HEALTH HISTORY d. Summarize current health status and health promotion/disease prevention UÊ *ÕÀ«ÃiÊ>`ÊVÀÀi>ÌÊÌÊ« ÞÃV>ÊiÝ>>Ì needs if client has no presenting problem 1. Begins the client–clinician relationship 3. Past health history 2. Identifies the client’s main concerns a. General state of health as client perceives 3. Provides information for risk assessment and it health promotion b. Childhood illnesses 4. Provides focus for physical examination and c. Major adult illnesses diagnostic/screening tests e. Psychiatric illnesses 5. Provides information about cultural variations f. Accidents/injuries in health beliefs and practices g. Surgeries/other hospitalizations h. Blood transfusions—dates and number of UÊ «iÌÃÊvÊÌ iÊ i>Ì Ê ÃÌÀÞ units 1. Reason for visit/chief complaint—brief state- 4. Current health status ment in client’s own words of reason for seek- a. Current medications—prescription, over- ing health care the-counter, herbal 2. Presenting problem/illness—chronological ac- b. Allergies—name of allergen, type of count of problem(s) for which client is seeking reaction care c. Tobacco, alcohol, illicit drugs—type, a. Description of principle symptoms should amount, frequency include d. Nutrition—24-hour diet recall, recent OLDCARTS mnemonic: weight changes, eating disorders, special (1) Onset diet (2) Location e. Screening tests—dates and results (3) Duration f. Immunizations—dates (4) Characteristics g. Sleep patterns (5) Aggravating/Associated factors h. Exercise/leisure activities (6) Relieving factors i. Environmental hazards (7) Temporal factors j. Use of safety measures—safety belts, (8) Severity smoke detectors b. Include pertinent negatives in symptom k. Disabilities—functional assessment if descriptions indicated c. Describe impact of illness/problem on client’s usual lifestyle

11 12 Chapter 2 General Health Assessment and Health Promotion

5. Family health history—provide information c. Abortions—spontaneous and induced about possible genetic, familial and environ- d. GTPAL—Gravida, Term, Preterm, Abor- mental associations with client’s health tion, Living children is a commonly used a. Age and health or age and cause of death method of obstetric history notation of immediate family members—parents, e. Any infertility evaluation and treatment siblings, children, spouse/significant other 8. Menstrual history—may include in separate b. Specific conditions to ask about include— section or in review of systems heart disease, hypertension, stroke, dia- a. Age at menarche, regularity, frequency, betes, cancer, epilepsy, kidney disease, duration, and amount of bleeding thyroid disease, asthma, arthritis, blood b. Date of last normal menstrual period diseases, tuberculosis, alcoholism, aller- c. Use of pads, tampons, douching gies, congenital anomalies, mental illness d. Abnormal uterine bleeding c. Indicate if client is adopted and/or does e. Premenstrual symptoms not know family health history f. Dysmenorrhea 6. Psychosocial/cultural health history g. Perimenopausal symptoms a. Living situation h. Age at menopause, use of hormone ther- b. Support system apy, postmenopausal bleeding c. Stressors (including violence) 9. Sexual history/contraceptive use—may in- d. Typical day clude in separate section, under current health e. Religious beliefs status, or in review of systems f. Outlook on present and future a. Age at first sexual g. Special issues to address with adolescent intercourse—consensual/nonconsensual clients include (HEADSS) Home, Educa- b. History of sexual abuse or sexual assault tion, Activities, Drugs, Sex, Suicide c. Sexual orientation h. Cultural assessment considerations d. Current sexual relationship(s) (1) Cultural/ethnic identification—place (1) Frequency of sexual intercourse of birth, length of time in country (2) Satisfaction or concerns with sexual (2) Communication—language spoken, relationship(s) use of nonverbal communication, use (3) Dyspareunia, orgasmic or libido of silence problems (3) Space—degree of comfort with dis- e. Sexually transmitted disease (STD)/ tance between self and other, degree human immunodeficiency virus (HIV) of comfort with touching by another risk assessment (4) Social organization—family structure (1) Total number of sexual partners and and roles, influence of religion number in past 3 months (5) Time—past, present or future ori- (2) Types of sexual contact—vaginal, oral, ented, view of time—clock-oriented and/or anal or social-oriented (3) Use of condoms or other barrier (6) Environmental control—internal or methods external locus of control, belief in su- (4) Previous history of sexually transmit- pernatural forces ted infections 7. Obstetric history—may include in separate (5) Use of injection drugs or sex with section, past health history or review of sys- partner who has used injection drugs tems—includes all pregnancies regardless of (6) Sex while drunk, stoned, or high outcome (7) Previous testing for HIV a. Gravidity—total number of pregnancies f. Current and future desire for pregnancy including a current pregnancy g. Contraceptive use b. Parity—total number of pregnancies (1) Establish if pregnancy is not a con- reaching 20 weeks or greater gestation cern—hysterectomy, not sexually ac- (1) Include term, preterm, and stillbirth tive, only sexually active with females, deliveries menopausal (2) Include length of each pregnancy, (2) Current method, length of time used, type of delivery, weight and sex of satisfaction, problems or concerns infant, length of labor, complications (3) Previous methods used, when, length during prenatal, intrapartum, or post- of time used, satisfaction, problems or partum periods, infant complications, concerns, reason for discontinuation cause of stillbirth if known Physical Examination (General Screening Examination) 13

10. Review of systems—used to assess common Â Physical Examination symptoms for each major body system to (General Screening avoid missing any potential or existing prob- Examination) lems—special focus for women’s reproductive health includes: • Purpose and correlation to health history a. Endocrine—menses, breasts, pregnancy, 1. Begins laying on of hands—diagnostic and thyroid, menopause therapeutic b. Genitourinary 2. Findings may indicate need for further health (1) In utero exposure to diethylstilbestrol history information (DES) if born before 1971 3. Takes into account normal physical variations (2) Uterine or ovarian problems of different age and racial/ethnic groups (3) History or symptoms of STD or pelvic infection • Techniques of examination (4) History or symptoms of vaginal 1. Inspection—observation using sight and smell infections a. Takes place throughout the history and (5) History of abnormal Pap tests—date, physical examination abnormality, treatment b. Includes general survey and body-system– (6) History or symptoms of urinary tract specific observations infection 2. Auscultation—use of hearing usually with (7) Symptoms of urinary incontinence stethoscope to listen to sounds produced by 11. Concluding question—is there anything else the body I need to know about your health in order to a. Diaphragm best for high-pitched sounds, provide you with the best health care? e.g., S1, S2 heart sounds b. Bell best for low-pitched sounds, e.g., large • Risk factor identification blood vessels 1. Consider prevalence (existing level of disease) 3. Percussion—use of light, brisk tapping on and incidence (rate of new disease) in general body surfaces to produce vibrations in relation population and in your client population to density of underlying tissue and/or to elicit 2. Determine risks specific to client related to the tenderness following: a. Provides information about size, shape, a. Gender location and density of underlying organs b. Age or tissue c. Ethnic or racial background b. Percussion sounds are distinguished by d. Family history intensity (soft–loud), pitch (high–low), and e. Environmental exposures quality f. Lifestyle c. Tympany—loud, high-pitched, drum- g. Geographic area like sound, e.g., gastric bubble, gas-filled h. Inadequate preventive health care bowel d. Hyperresonance—very loud, low- • Problem-oriented medical record—organized pitched, boom-like sound, e.g., lungs with sequence of recording information using SOAP emphysema format e. Resonance—loud, low-pitched, hollow 1. SOAP format a. S—subjective information obtained dur- sound, e.g., healthy lungs ing history f. Dull—soft-to-moderate, moderate- b. O—objective information obtained pitched, thud-like sound, e.g., liver, heart through physical examination and g. Flat—soft, high-pitched sound, very dull, laboratory/diagnostic test results e.g., muscle, bone c. A—assessment of objective and subjective 4. Palpation—use of hands and fingers to gather data to determine a diagnosis with ratio- information about body tissues and organs nale or a prioritized differential diagnosis through touch d. P—plan to include diagnostic tests, thera- a. Finger pads, palmar surface of fingers, peutic treatment regimen, client educa- ulnar surface of fingers/hands, and dorsal tion, referrals and date for reevaluation surface of hands are used 2. Problem list—list each identified existing or b. Light palpation—about 1 cm in depth, potential problem and indicate both onset and used to identify muscular resistance, areas a resolution date of tenderness and large masses or areas of 3. Progress notes—use SOAP format for informa- distention tion documented at follow-up visits 14 Chapter 2 General Health Assessment and Health Promotion

c. Deep palpation—about 4 cm in depth, 4. Head, eyes, ears, nose and throat used to delineate organs and to identify a. Head and neck less obvious masses (1) Skull and scalp—no masses or tenderness • Screening examination (2) Facial features—symmetrical and in 1. General appearance—posture, dress, groom- proportion ing, personal hygiene, body or breath odors, (3) Trachea—midline facial expression (4) Thyroid—palpable with no masses or 2. Anthropometric measurements tenderness, rises symmetrically with a. Height and weight swallowing b. Body mass index (BMI) provides mea- (5) Neck—full range of motion (ROM) surement of total body fat; weight (kg)/ without pain height (m2); tables available to calculate (6) Lymph nodes BMI based on the individual’s height and (a) Preauricular, postauricular, oc- weight cipital, tonsillar, submandibular, (1) Underweight—BMI less than 18.5 submental, superficial cervi- (2) Normal weight—BMI 18.5 to 24.9 cal, posterior and deep cervical (3) Overweight—BMI 25 to 29.9 chains, supraclavicular (4) Obesity—BMI 30 to 39.9 (b) Normal findings—less than 1 cm (5) Extreme obesity—BMI 40 or greater in size, nontender, mobile, soft, c. Waist circumference and discrete (1) Provides measurement of abdominal b. Eyes fat as an independent prediction of (1) Visual acuity risk for type 2 diabetes, dyslipidemia, (a) Snellen chart for central vision; hypertension, and cardiovascular dis- normal 20/20 ease in individuals with BMI between (b) Rosenbaum card or newspaper 25 and 39.9 (overweight and obesity) for near vision (2) Has little added value in disease risk (c) Impaired near vision—presbyopia prediction in individuals with BMI 40 (d) Impaired far vision—myopia or greater (extreme obesity) (2) Peripheral vision—estimated with vi- (3) Measure with horizontal mark at up- sual fields by confrontation test permost lateral border of right iliac (3) External eye structures—eyebrows crest and cross with vertical mark at equal; lids without lag or ptosis; lac- midaxillary line; place tape measure rimal apparatus without exudate, at the cross and measure in hori- swelling or excess tearing; conjunctiva zontal plane around abdomen while clear with small blood vessels and no standing exudate; sclera white or buff colored (4) In adult female increased relative risk is (4) Eyeball structures indicated at greater than 35 in (88 cm) (a) Cornea and lenses—no opacities 3. Skin, hair and nails or lesions a. Skin—color, texture, temperature, turgor, (b) Pupils—Pupils Equal, Round, moisture, lesions React to Light and Accommodate b. Hair—color, distribution, quantity, texture (PERRLA) c. Nails—color, shape, thickness (5) Extraocular muscle (EOM) function— d. Skin lesion characteristics—size, shape, symmetrical movement through the color, texture, elevation, exudate, location, six cardinal fields of gaze without lid and distribution lag or nystagmus (1) Primary lesions—occur as an initial, (6) Ophthalmoscopic examination—red spontaneous reaction to an internal reflex present with no clouding or or external stimulus (macule, papule, opacities; optic disc yellow to pink pustule, vesicle, wheal) color with distinct margins; arteri- (2) Secondary lesions—result from later oles light red and two-thirds of the evolution or trauma to a primary le- diameter of veins with bright light sion (ulcer, fissure, crust, scar) reflex; veins dark red and larger than e. ABCDEs of malignant melanoma—Asym- arterioles with no light reflex; no ve- metry, Borders irregular, Color blue/black nous tapering at the arteriole-venous or variegated, Diameter greater than 6 crossings mm, Elevation Physical Examination (General Screening Examination) 15

c. Ears c. Tactile fremitus—decreased with emphy- (1) Hearing evaluation sema, asthma, pleural effusion; increased (a) Whispered voice—able to hear with lobar pneumonia, pulmonary edema softly whispered words in each d. Percussion—resonant throughout lung ear at 1 to 2 feet fields (b) Weber test—tests for lateraliza- e. Auscultation—vesicular over most of lung tion of sound through bone con- fields; bronchovesicular near main bron- duction; normally hear sound chus and bronchial over trachea equally in both ears (1) Adventitious sounds—crackles (in- (c) Rinne test—compares bone and termittent, nonmusical, brief sound); air conduction of sound; normally rhonchi (low-pitched, snoring qual- air conducted (AC) sound is heard ity); wheezes (high-pitched, shrill for twice as long as bone con- quality); pleural friction rub (grating ducted (BC) sound (AC:BC = 2:1) or creaking sound) (d) Weber and Rinne tests help in dif- (2) Transmitted voice sounds/vocal res- ferentiating conductive and sen- onance—normally voice sounds are sorineural hearing loss muffled or indistinct; bronchophony, (2) External ears—symmetrical, no egophony, whispered pectoriloquy inflammation, lesions, nodules, or indicate fluid or a solid mass in lungs drainage 6. Cardiovascular system (3) Tragus tenderness may indicate otitis a. Blood pressure—less than 120/80 mm externa; mastoid process tenderness Hg and pulse 60 to 90 beats per minute may indicate otitis media (bpm), regular, not bounding or thready (4) Otoscopic examination b. Heart (a) External canal—no discharge, (1) Apical impulse—4th to 5th left inter- inflammation, lesions or foreign costal space (ICS) medial to the mid- bodies; varied amount, color, and clavicular (MCL) line, no lifts or thrills consistency of cerumen (2) Auscultation at 2nd right ICS, 2nd, (b) Tympanic membrane—intact, 3rd, 4th, 5th left ICS at the sternal bor- pearly gray, translucent, with cone der and 5th left ICS at the MCL of light at 5:00 to 7:00; umbo and (a) Assess rate and rhythm

handle of malleus visible; no bulg- (b) Identify S1 and S2 at each site—S1

ing or retraction heard best at apex, S2 heard best d. Nose and sinuses at base (1) Nasal mucosa pinkish red; septum (c) Identify extra heart sounds at midline each site

(2) Frontal and maxillary sinuses i. Physiologic split S2—may nontender normally be heard during e. Mouth and oropharynx inspiration

(1) Mouth—lips, gums, tongue, mucous ii. Fixed split S2—heard in inspi- membranes all pink, moist, without ration and expiration; may be lesions or inflammation; teeth—none heard with atrial septal defect missing, free from caries or breakage or right ventricular failure

(2) Oropharynx—tonsils; posterior iii. Increased S3—early diastole, wall of pharynx without lesions or low-pitched; may be normal inflammation in children, young adults, and 5. Respiratory system in late pregnancy; not normal a. Chest symmetrical, anterior/posterior di- in older adults

ameter less than transverse diameter; iv. Increased S4—late diastole, respiratory rate 16 to 20 breaths per min- low-pitched, may be normal ute; rhythm regular; no rib retraction or in well trained athletes and use of accessory muscles; no cyanosis or older adults; heard with aortic clubbing of fingers stenosis and hypertensive b. Anterior and posterior respiratory expan- heart disease sion—symmetrical movement when client v. Murmurs—systolic mur- inhales deeply mur may be physiologic (pregnancy) or pathologic 16 Chapter 2 General Health Assessment and Health Promotion

(diseased valves); diastolic tenderness (CVAT) may indicate kidney murmur usually indicates val- problem vular disease 8. Musculoskeletal system a) Note timing, duration, a. No gross deformities; body aligned; ex- pitch, intensity, pattern, tremities symmetrical; normal spinal cur- quality, location, radia- vature; no involuntary movements tion, respiratory phase b. Muscle mass and strength equal bilater- variations ally; full range of motion without pain b) Murmur of mitral steno- c. No inflammation, nodules, swelling, crepi- sis—early/late diastole, tus, or tenderness of joints low-pitched, grade I to 9. Neurologic system IV; heard loudest at apex a. Cranial nerves (CN)—CN II through XII without radiation; no re- routinely tested, CN I tested if abnormality spiratory phase variation is suspected vi. Clicks and snaps—heard with (1) CN I (olfactory)—test ability to iden- heart valve abnormalities tify familiar odors vii. Pericardial friction rub— (2) CN II (optic)—test visual acuity, pe- grating sound heard through- ripheral vision, and inspect optic discs out cardiac cycle; heard with (3) CN III, IV, VI (oculomotor, trochlear, pericarditis abducens)—observe for PERRLA, c. Neck vessels EOM function, and ptosis (1) No jugular venous distention (4) CN V (trigeminal)—palpate strength of (2) Carotid arteries—strong, symmetrical, temporal and masseter muscles, test no bruits for sharp/dull and light touch sensa- d. Extremities (peripheral arteries) tion on forehead, cheeks, and chin (1) No erythema, pallor or cyanosis, no (5) CN VII (facial)—observe for any weak- edema or varicosities; skin warm; cap- ness, asymmetry, or abnormal move- illary refill time less than 2 seconds; ments of face normal hair distribution; no muscle (6) CN VIII (acoustic)—assess auditory atrophy acuity; perform Weber and Rinne tests (2) Pulses strong and symmetrical—bra- (7) CN IX (glossopharyngeal) and CN X chial, radial, femoral, dorsalis pedis, (vagus)—observe ability to swallow; posterior tibial symmetry of movement of soft palate (3) Lymph nodes less than 1 cm, non- and uvula when client says “ah”; gag tender, mobile, soft and discrete— reflex; any abnormal voice quality axillary, epitrochlear, inguinal (8) CN XI (spinal accessory)—observe 7. Abdomen and palpate strength and symmetry a. Symmetrical, no lesions or masses; no vis- of trapezius and sternocleidomastoid ible pulsations or peristalsis muscles b. Active bowel sounds; no vascular bruits or (9) CN XII (hypoglossal)—observe tongue friction rubs for any deviation, asymmetry, or ab- c. No guarding, tenderness or masses on normal movement palpation b. Cerebellar function—smooth coordinated d. Liver border—edge smooth, sharp, non- gait, able to walk heel to toe, balance tender; no more than 2 cm below right maintained with eyes closed (Romberg costal margin test); rapid rhythmic alternating move- e. Spleen and kidneys—usually not palpable ments smooth and coordinated f. Aorta—slightly left of midline in upper ab- c. Sensory function—able to identify superfi- domen; less than 3 cm width cial pain and touch; able to identify vibra- g. Percussion—tympany is predominant tion on bony prominences and passive tone; dullness over organs or any masses position change of fingers and toes; nor- h. Liver span—normally 6 to 12 cm at the mal response to discriminatory sensation right MCL tests; all findings symmetrical i. Splenic dullness—6th to 10th ICS just pos- d. Deep tendon reflexes—brisk and sym- terior to midaxillary line on left side metrical (biceps, brachioradialis, triceps, j. No tenderness on fist percussion over the patellar, Achilles) costovertebral angle; costovertebral angle Physical Examination (General Screening Examination) 17

10. Mental status shaped circular motions in a vertical a. Physical appearance and behavior—well strip pattern over entire area including groomed, emotional status appropriate to nipples; do not squeeze nipples unless situation; makes eye contact; posture erect client indicates they have spontane- b. Cognitive abilities—alert and oriented, ous nipple discharge able to reason; recent and remote memory (3) Palpate each area of breast tissue us- intact; able to follow directions ing three levels of pressure—light, me- c. Emotional stability—no signs of depres- dium, and deep sion or anxiety; logical thought processes, (4) Follow same procedures for client no perceptual disturbances with implants as correctly placed im- d. Speech and language skills—normal voice plants are located behind breast tissue quality and articulation, coherent, able to (5) Include palpation of chest wall, follow simple instructions skin, and incision area in client with e. Mini Mental Status Examination mastectomy (MMSE)—standardized screening tool (6) Breast tissue—consistency varies used for mental status assessment from soft fat to firmer glandular tis- f. Depression screening tools—Beck Depres- sue, physiologic nodularity may be sion Inventory, Zung Self-Rating Depres- present, there may be a firm ridge of sion Scale, Geriatric Depression Scale compressed tissue under lower edge of breasts • Detailed reproductive examination (7) Describe any palpable mass or lymph 1. Breasts nodes in terms of location accord- a. The female breast extends from the sec- ing to clock face as examiner faces ond to the sixth ribs and from the sternal client—size, shape, mobility, consis- border to the midaxillary line tency, delimitation, and tenderness b. Inspect breasts with client in sitting posi- (8) Describe any nipple discharge in tion and hands pushing against hips; view terms of whether spontaneous/not breasts from all sides to assess for symme- spontaneous, bilateral/unilateral, try and skin changes single or multiple ducts, color, and (1) Tanner sexual maturity rating in consistency adolescent 2. Pelvic examination (2) Skin—smooth, color uniform, no ery- a. Positioning—client lying supine with head thema, masses, retraction, dimpling and shoulders elevated, lithotomy posi- or thickening tion, buttocks extending slightly beyond (3) Symmetry—breast shape or contour is edge of table, draped from midabdomen symmetrical; some difference in size to knees, drape depressed between knees of breasts and areola is common and to allow eye contact usually normal b. Inspection and palpation of external (4) Nipples—pointing in same direction; structures—mons pubis, labia majora and no retraction or discharge, no scaling; minora, clitoris, urethral meatus, vaginal long-standing nipple inversion is usu- introitus, paraurethral (Skene) glands, Bar- ally normal variation tholin glands, perineum c. Palpate axillary, supraclavicular, infra- (1) Tanner sexual maturity rating in clavicular lymph nodes with patient in sit- adolescent ting position and arms relaxed at sides (2) Mons pubis—pubic hair inverted d. Palpate breasts with client lying down, triangular pattern, skin smooth with arm above head, small pillow under uniform color shoulder/lower back on side being exam- (3) Labia majora—may be gaping or ined if needed to provide even breast tis- closed and dry or moist, tissue soft sue distribution and homogenous, covered with hair in (1) Include entire area from midaxillary postpubertal female line, across inframammary ridge and (4) Labia minora—moist and dark pink, fifth/sixth rib, up lateral edge of ster- tissue soft and homogenous num, across clavicle, back to midaxil- (5) Clitoris—approximately 2 cm or less lary line in length and 0.5 cm in diameter (2) Palpate using finger pads of middle (6) Urethral meatus—irregular opening three fingers with overlapping dime or slit 18 Chapter 2 General Health Assessment and Health Promotion

(7) Vaginal introitus—thin vertical slit or (4) Adnexa—fallopian tubes nonpalpable; large orifice, irregular edges from hy- ovaries ovoid, smooth, firm, mobile, menal remnants, moist slightly tender; size during reproduc- (8) Skene and Bartholin glands—opening tive years 3 cm × 2 cm × 1 cm of Skene glands just posterior to and (5) Note presence of enlargements, below urethral meatus, opening of masses, irregular surfaces, consis- Bartholin glands located posteriorly tency other than firm, deviation of on each side of vaginal orifice and not positions, immobility, tenderness usually visible f. Rectovaginal examination (9) Perineum—consists of tissue between (1) Purpose—palpate retroverted uterus; introitus and anus, smooth, may have screen for colorectal cancer in females episiotomy scar 50 years of age and older; assess pelvic (10) Note presence of any abnormal hair pathology distribution, discoloration, erythema, (2) Repeat the maneuvers of the biman- swelling, atrophy, lesions, masses, dis- ual examination with index finger in charge, malodor, fistulas, tenderness vagina and middle finger in rectum c. Pelvic floor muscles—form supportive (3) Rectum—smooth, nontender without sling for pelvic contents and functional masses; firm anal sphincter tone sphincters for vagina, urethra, and rectum, (4) Rectovaginal septum—smooth, intact, able to constrict introitus around examin- nontender, without masses ing finger, no anterior or posterior bulging of vaginal walls, incontinence, or protru- • Infection control sion of cervix or uterus when client bears 1. Prevention of contamination down a. Clean work surface for each client d. Inspection of internal structures b. Prepare equipment/supplies prior to (1) Vaginal walls—pink, rugated, homo- examination genous, may have thin, clear/cloudy, c. Conduct pelvic examination with at- odorless discharge tention to preventing contamination of (2) Cervix—midline, smooth, round, pink, equipment such as examination lights and about 2.5 cm diameter, protrudes 1–3 lubricant containers cm into vagina; points posteriorly 2. Standard precautions with anteverted uterus, anteriorly with a. Foundation for preventing infection trans- retroverted uterus, horizontally with mission during patient care midposition uterus; nabothian cysts b. Transmission of infectious agents requires may be present; os small and round three elements—source or reservoir for in- (nulliparous), may be oval, slit-like, fectious agent; susceptible host with por- or stellate if parous; may have area tal of entry receptive to the agent; mode of darker red epithelial tissue around of transmission from source of infectious os if squamocolumnar junction is on agent to susceptible host ectocervix c. Use applies to blood, all body fluids, secre- (3) Note presence of discoloration, ery- tions and excretions (except sweat), non- thema, swelling, atrophy, friable tis- intact skin, and mucous membranes sue, lesions, masses, discharge that is d. Wash hands immediately after gloves are profuse, malodorous, thick, curdy or removed, between patient contacts, and frothy, gray, green or yellow, adherent when otherwise indicated to vaginal walls e. Wear gloves when probability may ex- e. Palpation of internal structures ist of contact with blood, body fluids, (1) Vaginal walls—smooth, nontender secretions, excretions, mucous mem- (2) Cervix—smooth, firm, mobile, non- branes, nonintact skin, and contaminated tender, about 2.5 cm diameter, pro- materials trudes 1–3 cm into vagina f. Use mask, eye protection, face shield, (3) Uterus—smooth, rounded contour, gown as needed to protect skin and mu- firm, mobile, nontender; 5.5 to 8 cm cous membranes during procedures likely long and pear shaped in nulliparous to generate splashes or sprays of blood, female, may be 2 to 3 cm larger in body fluids, secretions, or excretions parous female; position anteverted, anteflexed, midplane, retroverted, or retroflexed Nongynecological Diagnostic Studies/Laboratory Tests 19

g. Routinely clean and disinfect environmen- e. Heavy smokers and individuals living at tal surfaces including frequently touched higher elevations may also have higher surfaces in patient care areas Hgb levels h. Adequately clean, disinfect, or sterilize 3. Red blood cell indices—provides information reusable equipment about size, weight, and Hgb concentration of i. Use proper disposal for contaminated RBCs; useful in classifying anemias single-use items a. Mean corpuscular volume (MCV)—aver- j. Dispose of needles and other sharp items age volume or size of a single RBC in proper puncture resistant containers; (1) Normal finding—80 to 95 mm3, do not recap, bend or break used needles; normocytic if recapping required use one-handed (2) Microcytic/abnormally small—seen scoop technique with iron deficiency anemia and k. Use mouthpiece, resuscitation bag, thalassemia other ventilation devices for patient (3) Macrocytic/abnormally large—seen resuscitation with megaloblastic anemias such as

vitamin B12 deficiency and folic acid Â NonGynecologicAL Diagnostic deficiency Studies/Laboratory Tests b. Mean corpuscular hemoglobin (MCH)— average amount or weight of Hgb within • Complete blood count (CBC) with differential an RBC 1. RBC count—measurement of red blood cells (1) Normal finding—27 to 31 pg/cell per cubic millimeter of blood (2) Causes for abnormalities same as with a. Normal findings (adult female)—4.2 to 5.4 MCV million/mm3 c. Mean corpuscular hemoglobin concentra- b. Low values—hemorrhage, hemolysis, dition (MCHC)—average concentration or etary deficiencies, hemoglobinopathies, percentage of Hgb within a single RBC bone marrow failure, chronic illness, (1) Normal finding—32 to 36 g/dL, medications normochromic c. High values—dehydration, diseases (2) Decreased concentration or hypo- causing chronic hypoxia such as con- chromic—seen with iron deficiency genital heart disease, polycythemia vera, anemia and thalassemia medications 4. White blood cell (WBC) count with differen- 2. Hematocrit (Hct)/Hemoglobin (Hgb)—rapid tial—provides information useful in evaluating indirect measurement of RBC count individual with infection, neoplasm, allergy, or a. Hct—percentage of total blood volume immunosuppression that is made up of RBCs a. Normal finding for total WBC (1) Normal findings (nonpregnant adult (adult)—5000 to 10,000/mm3 female)—37 to 47% b. Increased WBC count—seen with infec- (2) Normal findings (pregnant adult tion, trauma, inflammation, some malig- female)—33% or greater in first and nancies, dehydration third trimesters, 32% or greater in sec- c. Decreased WBC count—seen with some ond trimester drug toxicities, bone marrow failure, over- b. Hgb—measurement of total hemoglobin whelming infections, immunosuppression (which carries oxygen) in the blood d. May be elevated in late pregnancy and (1) Normal findings (nonpregnant adult during labor female)—12 to 16 g/dL e. Neutrophils—increased with acute bacte- (2) Normal findings (pregnant adult fe- rial infections and trauma; increased im- male)—11 g/dL or greater in first and mature forms (band or stab cells) referred third trimesters, 10.5 g/dL or greater to as a “shift to left,” seen with ongoing in second trimester acute bacterial infection c. Low values—anemia, hemoglobinopa- f. Basophils and eosinophils—increased thies, cirrhosis, hemorrhage, dietary defi- with allergic reactions and parasitic infec- ciency, bone marrow failure, renal disease, tions; not increased with bacterial or viral chronic illness, some cancers infection d. High values—erythrocytosis, poly- g. Lymphocytes and monocytes—increased cythemia vera, severe dehydration, severe with chronic bacterial and acute viral chronic obstructive pulmonary disease infections 20 Chapter 2 General Health Assessment and Health Promotion

5. Peripheral blood smear—microscopic exami- a. Symptoms of diabetes plus random non- nation of smear of peripheral blood to exam- fasting glucose concentration of 200 mg/ ine RBCs, platelets, and leukocytes dL or greater 6. Platelet count—used to evaluate abnormal b. Fasting glucose of 126 mg/dL or greater bleeding or blood clotting c. 2-hour post glucose 200 mg/dL or greater a. Normal finding (adult)—150,000 to d. Repeat testing on a subsequent day to 400,000/mm3 confirm diagnosis b. Low count (thrombocytopenia)—hyper- e. ADA recommends using fasting glucose splenism, hemorrhage, leukemia, cancer rather than OGTT for screening

chemotherapy, infection 4. HbA1c or A1c c. High count (thrombocytosis)—some a. Not presently recommended for the diag- malignant disorders, polycythemia vera, nosis of diabetes rheumatoid arthritis b. Gold standard for measurement of long- term (previous 60–90 days) glycemic con- • Urinalysis—dipstick and/or microscopic evalua- trol in individuals with diabetes tion of urine c. Reliable tool for evaluating need for drug 1. Includes evaluation of appearance, color, therapy and monitoring effectiveness of odor, pH, protein, specific gravity, leukocyte therapy esterase, nitrites, ketones, crystals, casts, glu- d. Good diabetic control—less than 7% cose, WBCs, and RBCs 2. Obtain midstream clean catch specimen so • Blood urea nitrogen (BUN) and creatinine—used culture can be performed if urinalysis indi- in evaluation of renal function cates infection 1. BUN—indirect measure of renal and liver 3. Normal findings function a. No nitrites, ketones, crystals, casts, or a. Normal finding (adult)—10 to 20 mg/dL glucose b. Increased levels—hypovolemia, dehydra- b. Clear, amber yellow, aromatic tion, reduced cardiac function, gastroin- c. pH 4.6 to 8.0 testinal bleeding, starvation, sepsis, renal d. Protein 0 to 8 mg/dL disease e. Specific gravity (adult)—1.005 to 1.030 c. Decreased levels—liver failure, malnutri- f. Leukocyte esterase negative tion, nephrotic syndrome g. WBCs 0 to 4 per high power field (HPF) 2. Serum creatinine—indirect measure of renal h. RBCs at 2 or less function a. Normal finding (adult female)—0.5 to 1.1 • Blood glucose—used for diagnosis and evaluation mg/dL of diabetes mellitus b. Increased levels—renal disorders, 1. Fasting glucose dehydration a. No caloric intake for at least 8 hours c. Decreased levels—debilitation and de- b. Normal finding (adult)—less than 100 creased muscle mass mg/dL c. Impaired fasting glucose—100 to 125 • Lipid profile—determines risk for coronary heart mg/dL disease and evaluation of hyperlipoproteinemia d. Diagnostic for diabetes—126 mg/dL or 1. Includes total cholesterol, triglycerides, high greater density lipoproteins (HDL), and low density 2. Two-hour postload glucose during oral glucose lipoproteins (LDL) tolerance test (OGTT) 2. Fast for 12 to l4 hours prior to obtaining a. Sample obtained 2 hours after a glucose sample load containing the equivalent of 75 g of 3. Total cholesterol normal level (adult)—less glucose dissolved in water than 200 mg/dL; may be elevated in pregnancy b. Normal finding—less than 140 mg/dL 4. Triglycerides normal finding (adult fe- c. Impaired glucose tolerance—140 mg/dL male)—35 to 135 mg/dL; may be elevated in to 199 mg/dL pregnancy d. Diagnostic for diabetes—200 mg/dL or 5. HDL—removes cholesterol from peripheral greater tissues and transports to liver for excretion 3. American Diabetes Association (ADA) criteria a. Normal level (adult)— 40 mg/dL or greater for the diagnosis of diabetes mellitus b. Low levels associated with increased risk for heart and peripheral vascular disease Nongynecological Diagnostic Studies/Laboratory Tests 21

6. LDL—cholesterol carried by LDL can be de- a. Hemagglutination inhibition (HAI) test— posited into peripheral tissues used to detect immunity to rubella and a. Normal finding (adult)—less than 130 diagnose rubella infection mg/dL (1) Titer of 1:10 or greater indicates im- b. High levels associated with increased risk munity to rubella for heart and peripheral vascular disease (2) High titers (1:64 or greater) may indicate current rubella infection • Thyroid function studies b. Rubella IgM antibody titer—used if preg- 1. Thyroid stimulating hormone (TSH)—used to nant woman has a rash suspected to be diagnose hyperthyroidism, primary hypothy- from rubella; if titer is positive recent roidism, differentiate primary from secondary infection has occurred; IgM antibodies hypothyroidism, and to monitor thyroid reappear 1 to 2 days after onset of rash and placement or suppression therapy disappear 5 to 6 weeks after infection a. Normal finding (adult)— 0.4 to 4.7 2. HIV tests—used for diagnosis of human im- mU/mL munodeficiency virus infection b. Increased levels—seen with primary hypo- a. Sensitive screening tests—enzyme immu- thyroidism and thyroiditis noassay (EIA) or rapid test c. Decreased levels—seen with secondary b. Reactive screening tests must be con- hypothyroidism, hyperthyroidism; sup- firmed by supplemental test—Western pressive doses of thyroid medication blot or immunofluorescence assay (IFA) d. Debate on lowering upper limit of nor- c. HIV antibody detectable in 95% of indi- mal to 3.0 mU/mL to detect mild thyroid viduals within 6 months of infection disease d. Polymerase chain reaction (PCR)—used

2. Free thyroxine (FT4)—used in diagnosis of thy- to confirm indeterminate Western blot roid disease results or negative results in persons with a. Normal finding (adult female)—0.58 to suspected HIV infection 1.64 ng/dL e. HIV plasma ribonucleic acid (RNA) test- b. Increased levels—hyperthyroidism and ing may be used if suspect recent HIV acute thyroiditis infection before development of immune c. Decreased levels—hypothyroidism response; positive HIV RNA testing should

3. Total thyroxine (T4) be confirmed with subsequent antibody a. Normal finding (adult female)—4.5 to 12.0 testing to document seroconversion µg/dL 3. Hepatitis B (HBV) tests b. Measurement affected by increases in a. Hepatitis B surface antigen (HBsAg)—rises thyroxine-binding globulin (TBG) before onset of clinical symptoms, peaks c. Causes for increased TBG include preg- during first week of symptoms and returns nancy, oral contraceptive use, and estro- to normal by time jaundice subsides gen therapy (1) Indicates active HBV infection—individual is infectious • Blood type and Rh factor—used to determine (2) Individual is considered a carrier if blood type prior to donating or receiving blood HBsAg persists and to determine blood type in pregnant women b. Hepatitis B surface antibody (HBsAb)— 1. Blood types are grouped according to presence appears 4 weeks after disappearance of or absence of antigens A, B, and Rh on RBCs surface antigen 2. Individual without a particular antigen may (1) Indicates end of acute infectious develop antibodies to that antigen if exposed phase and signifies immunity to sub- through blood transfusion or fetal-maternal sequent infection blood mixing (2) Also used to denote immunity after 3. Blood type O negative (universal donor be- administration of hepatitis B vaccine cause no antigens on RBCs), AB positive (uni- 4. Tuberculosis—purified protein derivative versal recipient because no antibodies to react (PPD) test to transfused blood) a. Usually positive within 6 weeks after infection • Infectious disease screening b. Does not indicate whether infection is ac- 1. Rubella (German measles) tive or dormant c. Centers for Disease Control and Preven- tion (CDC) definition of positive PPD 22 Chapter 2 General Health Assessment and Health Promotion

(1) High risk population 5 mm induration c. Gamma-glutamyl transpeptidase (GGT) or greater (1) Normal finding—8–38 U/L (2) Moderate risk population 10 mm in- (2) Elevated levels with liver disease, duration or greater myocardial infarction, pancreatic dis- (3) General population 15 mm induration ease, and heavy or chronic alcohol use or greater d. Once positive reaction, usually persists for • Stool for occult blood life 1. Annual screen for individuals over 50 years e. False negatives may result from incorrect of age and for evaluation of gastrointestinal administration (must be intradermal) or conditions that may cause gastrointestinal (GI) immunosuppression bleeding f. False positive may result if individual 2. Positive test—may indicate GI cancer or pol- had prior immunization with bacillus of yps; peptic ulcer disease; inflammatory or Calmette and Guerin (BCG) vaccine ischemic bowel disease; GI trauma; bleeding g. PPD test is contraindicated if history of caused by medications BCG vaccination or active TB since severe 3. Several interfering factors can cause false posi- local reaction can occur tives or negatives a. Red meat and some raw fruits/vegetables • Sickle cell screening (Sickle Cell Prep, Sickledex)— if consumed within 3 days prior or during used to screen for sickle cell disease and trait the test period can result in false positive 1. Positive test—presence of Hgb S indicates b. Large amounts of vitamin C consumed sickle cell disease or trait within 3 days prior to or during the test 2. Hgb electrophoresis is definitive test to be per- period can result in false negative formed if screening test is positive; identifies 4. Positive test requires further evaluation with Hgb type and quantity sigmoidoscopy, colonoscopy, or barium enema

• Liver function studies Â Health Maintenance and Risk 1. Bilirubin Factor Identification a. Normal findings (adult)—total bilirubin 0.3 to 1.0 mg/dL; direct (conjugated) bili- • Nutrition rubin 0.1 to 0.3 mg/dL; indirect (unconju- 1. Evaluation of nutritional status gated) bilirubin 0.2 to 0.8 mg/dL a. Anthropometric measurements—height, b. Elevated direct bilirubin level—occurs weight, BMI, waist circumference with gallstones and obstruction of extra- b. General appearance—skin, hair, muscle hepatic duct mass c. Elevated indirect bilirubin level—seen c. Biochemical measurements—Hgb/Hct, with hepatocellular dysfunction (hepatitis, lipid analysis, serum albumin, serum glu- cirrhosis) and hemolytic anemias cose, serum folate 2. Albumin d. 24-hour diet recall or 3 to 4 day food diary a. Normal finding (adult)—3.5 to 5.0 g/dL e. Use of vitamin, mineral, and herbal b. Increased levels—dehydration supplements c. Decreased levels—seen with liver disease, 2. Dietary Guidelines for Americans (US Depart- malabsorption syndromes, nephropathies, ment of Health and Human Services severe burns, malnutrition, and inflamma- [USDHHS], 2005) tory disease a. Eat a variety of nutrient-dense foods from 3. Liver enzymes the basic food groups a. Alkaline phosphatase (ALP) b. Balance the food you eat with physical ac- (1) Normal finding—30 to 120 U/L tivity to maintain or improve weight (2) Elevated levels—liver disease, bone c. Eat a good variety of two and one half cups disease, and myocardial infarction of vegetables and two cups of fruit each b. Aspartate aminotransferase (AST), alanine day (reference 2000 calories intake) aminotransferase (ALT), lactic dehydroge- d. Eat six ounces of grains with at least one nase (LDH), and 59 nucleotidase half whole grain products each day (1) Normal findings—AST 0–35 U/L, ALT e. Eat three cups of fat-free or low-fat milk or 4–36 U/L, LDH 100–190 U/L equivalent milk products each day (2) Useful in differentiating cause for ALP elevation Health Maintenance and Risk Factor Identification 23

f. Eat five and one half ounces of meat and 5. Iron requirements for nonpregnant women beans choosing low fat lean meats, more a. 14 to 18 years of age—15 mg/dL each day fish, beans, peas, nuts and seeds b. 19 to 50 years of age—18 mg/dL each day g. Choose a diet low in fat (20 to 35% of calo- c. 51 years of age or older—8 mg/dL each day ries), saturated fats (< 10% of calories), d. Sources—meat, fish, poultry, fortified ce- trans fats as low as possible, and choles- reals, dried fruits, dark green vegetables, terol (300 mg or less/day) supplements h. Choose and prepare foods and beverages 6. Special concerns with little added sugar a. Eating disorders—see section on Lifestyle/ i. Choose a diet moderate in salt and sodium Family Alterations in Nongynecological (< 2300 mg/day—approximately one tea- Disorders chapter spoon of salt) b. Vegetarians—plan diet to avoid deficien-

j. Drink alcoholic beverages only in mod- cies in protein, calcium, iron, vitamin B12, eration (no more than one drink daily for and vitamin D women); one drink = 12 ounce of beer, 5 c. Older adults—consider effects of chronic ounces of wine, 1.5 ounces of hard liquor illness, medications, isolation, decrease in 3. Calcium and vitamin D requirements for ability to taste and smell, limited income women a. National Institute of Health/National In- • Physical activity stitute of Arthritis and Musculoskeletal 1. There is strong evidence that regular physical and Skin Diseases (NIAMS) (2009) activity lowers risk for heart disease, stroke, (1) 14 to 18 years of age—1300 mg/day of high blood pressure, adverse lipid profile, type calcium; same amount if pregnant or 2 diabetes, metabolic syndrome, colon and lactating breast cancers; prevents weight gain and pro- (2) 19 to 50 years of age—1000 mg/day of motes weight loss; improves cardiovascular calcium, same amount if pregnant or and muscular fitness; reduces depression; im- lactating proves cognitive function in older adults. (3) 51 years of age and older—1200 mg/ 2. Sixty percent of Americans are not regularly day of calcium physically active and 25% report no physical (4) Adults—400 to 600 IU/day of vitamin D activity at all. b. National Osteoporosis Foundation (2008) 3. Physical Activity Guidelines for Americans (1) Adults under age 50—1000 mg/day (USDHHS, 2008) of calcium; 400 to 800 IU/day of a. Engage in at least 150 minutes of moder- vitamin D ate intensity or 75 minutes of vigorous (2) Adults age 50 and over—1200 mg/day intensity aerobic physical activity each of calcium; 800 to 1000 IU of vitamin D week; performed for at least 10 minutes c. Sources of calcium—milk, yogurt, soy- per episode; spread throughout the week beans, tofu, canned sardines and salmon b. Moderate intensity exercise achieves 50 to with edible bones, cheese, fortified cereals 69% of maximum heart rate—maximum and orange juice, supplements average heart rate equals 220 minus age d. Sources of vitamin D—fortified milk, egg c. Examples of aerobic physical activity— yolks, saltwater fish, liver, supplements, brisk walking, running, bicycling, jumping regular exposure to direct sunlight without rope, swimming sunscreen d. Engage in muscle strengthening activities 4. Folate requirements for women of childbear- of moderate or high intensity involving all ing age major muscle groups 2 or more days each a. 0.4 mg folic acid/day week b. Women of childbearing age who have had e. Examples of muscle strengthening activi- an infant with neural tube defect or who ties—weight lifting, exercises with elastic have seizure disorders or insulin depen- bands or use of body weight (push-ups, dent diabetes may benefit from a higher tree climbing) for resistance dose of 4 mg folic acid/day starting 1 f. Include bone strengthening activity in month before trying to become pregnant exercise regimen—running, brisk walking, c. Sources—dried beans, leafy green veg- weight training, tennis, dancing etables, citrus fruits and juices, fortified cereals; most multivitamins contain 0.4 • Routine screening recommendations mg folic acid 1. Breast self-examination (BSE) 24 Chapter 2 General Health Assessment and Health Promotion

a. American Cancer Society (ACS)—begin- ative HPV test perform Pap tests no more ning in their 20s, inform of benefits and than every 3 years limitations of BSE and provide instruction 6. Chlamydia screening—CDC—yearly screening for women who choose to do BSE; it is ac- for all sexually active females 25 years of age or ceptable for women to choose not to do younger BSE or to do BSE irregularly 7. Blood Pressure—National High Blood Pressure b. American College of Obstetricians and Gy- Education Program (NHBPEP) of the National necologists (ACOG)—adult women should Heart, Lung and Blood Institute (NHLBI)—at perform BSE monthly least every 2 years for adults 2. Clinical breast examination 8. Cholesterol a. ACS—every 3 years from age 20 to 39 years a. Third Report of the National Cholesterol b. American College of Obstetricians and Gy- Education Program (NCEP) Expert Panel necologists (ACOG) periodic evaluation, on Detection, Evaluation, and Treatment yearly or as appropriate for women older of High Blood Cholesterol in Adults (Adult than age 18 years Treatment Panel III or ATP III)—Recom- c. ACS and ACOG—yearly clinical breast ex- mendations for Cholesterol Screening amination for women age 40 and older (2001) 3. Mammogram (1) Fasting lipid profile (total cholesterol, a. ACS—yearly beginning at age 40 years LDL, HDL, triglycerides) once every 5 b. ACOG—every 1–2 years from age 40–49 years beginning at age 20 years years, then yearly (2) Total cholesterol 4. Magnetic Resonance Imaging (MRI) (a) Desirable level—less than 200 a. ACS and ACOG—not recommended for mg/dL routine breast cancer screening in women (b) Borderline high—200 to 239 with average risk (< 15% lifetime risk) mg/dL b. ACS—combination of yearly mammogram (c) High—240 mg/dL or greater and MRI for women at high risk (> 20% (3) LDL lifetime risk) starting at 30 years of age (a) Optimal level—less than 100 c. ACS—discuss risk and benefits of com- mg/dL bined yearly mammogram and MRI for (b) Near optimal/above optimal—100 women at moderately increased risk (15 to to 129 mg/dL 20%) (c) Borderline high—130 to 159 d. ACOG—combination of yearly mammo- mg/dL gram and MRI in women with BRCA gene (d) High—160 to 189 mg/dL mutation beginning at age 25 or younger (e) Very high—190 mg/dL or greater based on earliest age of onset in family (4) HDL e. Risk assessment tools—BRCAPRO, Claus (a) Low—less than 40 mg/dL (consid- model, Tyrer-Cuzick model ered a risk for CHD) 5. Pap test (b) High—60 mg/dL or greater (pro- a. ACS—begin approximately 3 years after tective against CHD) woman begins having vaginal intercourse (5) Triglycerides but not later than 21 years of age (a) Normal—less than 150 mg/dL b. ACOG—begin at age 21 years (b) Borderline high—150 to 199 c. ACS—perform yearly if using conventional mg/dL pap smear or every 2 years if using liquid- (c) High—200 mg/dL or greater based test b. CHD risk factors for women include being d. ACOG—perform every 2 years for women 55 years of age or older, family history of between ages 21 years to 29 years premature CHD (male relative < 55 years, e. ACS and ACOG—for women age 30 and female relative < 65), cigarette smoking, older who have had 3 consecutive satis- hypertension, HDL at less than 40 mg/dL, factory normal Pap tests, screening may diabetes mellitus be done every 3 years unless history of c. Desirable cholesterol is less than 200 mg/ in utero DES exposure, HIV infection or dL, HDL 60 mg/dL or greater, LDL at less immunosuppression than 130 mg/dL f. ACOG—for women age 30 and older with 9. Fecal occult blood test—ACS and ACOG yearly combination of negative Pap test and neg- beginning at age 50 Health Maintenance and Risk Factor Identification 25

10. Sigmoidoscopy a. Screen all women 65 years of age or older a. ACS and ACOG—every 5 years beginning for osteoporosis/osteopenia with BMD at age 50 (or colonoscopy every 10 years test or double contrast barium enema every 5 b. Screen postmenopausal women less than years) 65 years of age with risk factors b. More frequent testing and starting at younger age for those with risk factors in- • Immunizations cluding inflammatory bowel disease and 1. Hepatitis B personal or family history of colonic pol- a. Effective in 95% of cases in preventing yps or colon cancer hepatitis B virus (HBV) infection 11. Plasma glucose—American Diabetic Associa- b. High-risk groups for whom HBV vaccination recommendations tion is recommended include, but are not a. Fasting plasma glucose every 3 years start- limited to, individuals who have multiple ing at age 45 sex partners; are household contacts or b. More frequent testing and starting at sex partners of those with HBV infection; younger age for those with risk factors in- are injection drug users; are healthcare cluding blood pressure higher than 140/90 workers or are otherwise at occupational mm Hg; diabetes in first-degree relative; risk; inmates of long-term correctional African American, Asian, Hispanic, Native institutions American; obesity at 120% or greater of c. Three-dose series with the second and desirable weight or BMI at 27 or higher; third doses at 1 and 6 months after the history of gestational diabetes or baby first dose weighing more than 9 pounds at birth; 2. Influenza HDL at less than 40 mg/dL or triglyceride a. Recommended for all individuals who level at 250 mg/dL or greater want to reduce likelihood of getting influ- 12. Thyroid function enza or spreading it to others a. United States Prevention Task Force b. Recommended yearly for all individuals (USPTF)—routine screening for thyroid age 50 years and older function is not warranted in asymptom- c. Recommended yearly for younger indi- atic individuals viduals with pulmonary, cardiovascular, or b. ACOG—TSH periodically for women with other chronic medical disorders and those an autoimmune condition or strong fam- who may transmit influenza to individuals ily history of thyroid disease at increased risk 13. Tuberculosis d. Recommended for all women who will a. Centers for Disease Control and Preven- be in the second or third trimesters of tion (CDC) and ACOG—perform on all pregnancy during the influenza season; individuals at high risk administration of influenza vaccine is con- b. See section on Respiratory Disorders in sidered safe at any stage of pregnancy Nongynecological Disorders chapter for e. Trivalent inactivated influenza vaccine more information on tuberculosis and risk (TIV) given IM in one dose factors f. Live attenuated influenza vaccine (LAIV) 14. Vision—American Academy of Ophthalmology given intranasally—only use for healthy, recommendations for screening for visual acu- nonpregnant individuals younger than 50 ity and glaucoma by an ophthalmologist years of age a. Every 3 to 5 years for African Americans 3. Pneumococcus age 20 to 39 a. Recommended one time for all immuno- b. Every 2 to 4 years for individuals age 40 to competent individuals age 65 and older 64 and every 1 to 2 years beginning at age b. Recommended for individuals 64 years of 65 regardless of race age or younger who have chronic illness, c. Yearly for diabetic individuals regardless of functional or anatomic asplenia, immuno- age compromising conditions, organ or bone 15. Dental—American Dental Association recom- marrow transplant recipients, and those mends that adults should have routine dental whose living conditions place them at care and preventive services including oral high risk for pneumonia cancer screening at least once every year c. A single revaccination 5 or more years af- 16. Bone mineral density (BMD)—National Osteo- ter the initial vaccination is recommended porosis Foundation (NOF) recommendations for individuals who received the vaccine 26 Chapter 2 General Health Assessment and Health Promotion

5 or more years previously and were less c. Recommended as a catch-up vaccination than 65 years old at the time of the vac- for females 13 to 26 years of age who did cination; individuals with functional or not receive it when younger anatomic asplenia, organ or bone marrow 10. Meningococcal transplant recipients; and immunocom- a. Recommended for all individuals 11–18 promised individuals years of age; college freshmen living in 4. Rubella dormitories; individuals with anatomic or a. Recommended for all nonpregnant functional asplenia; individuals traveling women of childbearing age who lack doc- to regions where meningococcal disease is umented evidence of immunity or prior hyperendemic or epidemic immunization after 12 months of age b. One-time dose b. Contraindications—pregnancy (advise 11. Immunizations during pregnancy not to become pregnant for 4 weeks after a. Live attenuated-virus vaccines should not vaccination); immunocompromised indi- be given during pregnancy viduals except those who are HIV positive; b. Inactivated virus vaccines, bacterial vac- hypersensitivity to neomycin cines, toxoids, and tetanus immunoglobu- c. May be given to breastfeeding women lin may be given if indicated 5. Tetanus and diphtheria a. Tetanus-diphtheria (Td) vaccine series • Smoking cessation should be completed 1. Overall, 17.4% of adult women currently b. Booster vaccination every 10 years for smoke cigarettes (CDC data from 2007). adults 2. In women of reproductive age, 22.4% currently c. May be given in pregnancy if indicated in smoke cigarettes (CDC data from 2006). second or third trimester 3. Of female high school students, 19.4% cur- 6. Varicella rently smoke cigarettes (CDC data from 2007). a. Recommended for all adolescents and 4. Smoking cessation interventions should be adults who have not had chickenpox, individualized in relation to the smoker’s given in two doses 4 to 8 weeks apart physical and psychological dependence and b. Contraindications—pregnancy (advise the stage of readiness for change. not to become pregnant for 4 weeks after 5. Behavior modification strategies—provide vaccination), history of anaphylactic reac- self-help materials and/or refer to a smoking tion to neomycin, immunocompromised cessation class. individuals 6. Pharmacologic aids 7. Zoster (shingles)—one time dose recom- a. Nicotine replacement therapy (gum, mended for all individuals 60 years of age or patches, inhalers, nasal spray, lozenges)— older regardless of previous history of herpes help to reduce the physical withdrawal zoster (shingles) or chickenpox symptoms that occur with smoking 8. Hepatitis A cessation. a. Recommended for individuals who live (1) Major side-effects—local skin reac- in or are traveling to countries with high tions with patch; mouth and throat levels of Hepatitis A infection; intravenous irritation with gum, lozenge, and drug users; those with occupational expo- inhaler; nasal irritation with spray; sure risks; food handlers; and individuals headache; dizziness; nausea with chronic liver disease or clotting factor (2) Contraindications—serious cardiac disorders arrhythmias, severe angina, recent b. Two doses at least 6 months apart myocardial infarction, concurrent c. Combination hepatitis A and hepatitis B smoking, pregnancy category D vaccine given in three doses with second (3) Client education dose 1 month after first dose and third (a) Individual must stop smoking dose 6 months after first dose before initiating nicotine replace- 9. Human papilloma virus (HPV) ment therapy a. Recommended as routine vaccination for (b) Provide specific instructions for females 11 to 12 years of age; may be given the chosen route of delivery as young as 9 years of age b. Bupropion hydrochloride sustained re- b. Three doses with second dose 2 months lease tablets—reduces cravings smokers after first dose and third dose 6 months experience; exact manner of action un- after first dose known; probably acts on brain pathways Health Maintenance and Risk Factor Identification 27

involved in nicotine addiction and stimuli other than touch, communication withdrawal about needs and desires (1) Major side effects—insomnia, dry b. Sexual lifestyle—bisexuality, heterosexual- mouth, nausea, skin rash ity, homosexuality, long-term monogamy, (2) Contraindications—seizure disorder, serial monogamy, multiple partners, eating disorder, use of an MAO inhibi- celibacy tor, concomitant use of other forms of 4. Sexual response cycle bupropion a. Masters and Johnson (four phases)— (3) Pregnancy category B; not recom- excitement (arousal), plateau, orgasm, mended during breastfeeding resolution (4) Client education b. Kaplan (three phases)—desire, excite- (a) Individual should initiate medica- ment, orgasm tion 1 to 2 weeks before smoking c. Basson (nonlinear model)—demonstrates cessation that emotional intimacy, sexual stimuli, (b) Recommended duration of ther- and relationship satisfaction affect female apy is up to 6 months sexual response c. Varenicline tablets—reduces withdrawal 5. Female sexual dysfunction symptoms; blocks effect of nicotine if indi- a. Etiology may include relationship factors, vidual resumes smoking; nicotinic acetyl- medical conditions, medication side ef- choline receptor partial agonist fects, psychological factors, sexual abuse (1) Major side-effects—nausea, changes history in dreaming, constipation, gas, vomit- b. Must cause personal distress to be consid- ing, neuropsychiatric symptoms ered a sexual dysfunction (2) Contraindications—precautions c. May be persistent or recurrent, lifelong or with psychiatric disorders and renal acquired, generalized or situational impairment d. Assessment—thorough health history, (3) Pregnancy category C; not recom- focused sexual and gynecological history, mended during breastfeeding complete physical examination, focused (4) Client education gynecological examination (a) Individual should initiate medi- e. Management—PLISSIT model for education 1 week before smoking cation, counseling, referral; treatment cessation of related medical problems; change in (b) Concomitant use of nicotine medications replacement may increase side f. Classification of female sexual dysfunction effects (1) Hypoactive sexual desire disorder— (c) Discontinue medication and re- hypoactive sexual desire; sexual aver- port any agitation, depression, sion disorder and suicidal ideation. (2) Sexual arousal disorder—inability to attain or maintain sufficient sexual ex- • Safety—Address use of seat belts, safety helmets, citement; may have lack of lubrication smoke alarms, occupational safety, and other in- or feeling of erotic genital sensations jury prevention (3) Sexual orgasmic disorder—difficulty, delay in, or absence of orgasm follow- • Sexuality ing sufficient stimulation and arousal 1. Sexual history—see section on Health History (4) Sexual pain disorders in this chapter (a) Dyspareunia—genital pain asso- 2. PLISSIT model used by clinicians who are not ciated with sexual intercourse sex therapists or psychiatrists/psychologists to (b) Vaginismus—involuntary con- address sexual concerns and to make appro- traction of musculature of the priate referrals—Permission giving, Limited outer third of the vagina that in- Information giving, Specific Suggestions, In- terferes with vaginal penetration tensive Therapy (c) Noncoital sexual pain disorder— 3. Sexual practices genital pain induced by non- a. Sexuality includes a wide range of behav- coital sexual stimulation; e.g., iors—sexual intercourse, fantasy, self- endometriosis, vestibulitis, genital stimulation, noncoital pleasuring, erotic mutilation or trauma 28 Chapter 2 General Health Assessment and Health Promotion

6. Male sexual dysfunction (9) Dietary management for a. Erectile disorder—inability to obtain or phenylketonuria maintain an adequate erection suitable for (10) STD testing and treatment as sexual activity; factors may include per- indicated formance anxiety, neurologic and vascular (11) HIV counseling and testing as disorders, diabetes, hormonal deficiency, indicated alcoholism, medications (12) Medication changes as needed to b. Premature ejaculation—inability to delay avoid teratogens such as some antisei- ejaculation to a point that is mutually zure medications desirable for both partners; factors may b. Resources/referrals include sexual inexperience and anxiety (1) Genetic testing and counseling as indicated—repeated spontaneous Â Preconception Care abortions, ethnic background that is high risk for autosomal recessive dis- • Historical factors linking birth defects and certain order, previous infant with congenital drugs anomaly, age 35 or older 1. Thalidomide (2) Dietary counseling 2. Radiation exposure (3) Substance abuse treatment 3. DES (4) Domestic violence resources

• Goals of preconception care Â Parenting 1. Assistance in preventing unintended pregnancies • Definitions 2. Identification of risk factors that could affect 1. Parent(s)—the person or persons responsible reproductive outcomes for a child’s care and long-term welfare 3. Identification and management of medical 2. Infant–parent attachment—process by which conditions that could be affected by pregnancy parent and infant develop an affectionate, re- or could affect reproductive outcomes, e.g., ciprocal relationship that endures over time diabetes 4. Initiation of education and desired preventive • Conditions promoting attachment interventions prior to conception 1. Parental emotional well-being and ability to trust • Timing of preconception care—integrate into well- 2. Social support system woman visits for all reproductive-age women 3. Competent level of communication and caregiving skills • Components of preconception care 4. Proximity with the infant 1. Assessment—family history, medical/surgical history, infectious disease history, obstetric • Risk factors for abuse or neglect history, environmental history, cultural health 1. Immaturity of parent(s)—adolescent parents beliefs/practices, psychosocial history includ- at high risk ing violence, nutrition assessment, paternal 2. Isolation/lack of support system health history 3. Parent rejected or abused as child 2. Education/counseling and interventions 4. Emotional instability a. Health promotion/disease prevention/risk 5. Lack of knowledge about development and reduction care of children (1) Rubella, varicella and hepatitis B vac- 6. Low self-esteem cinations if needed 7. Stressful situations—spousal abuse, poverty, (2) Nutrition counseling for weight loss or unemployment gain as needed (3) Smoking cessation • Anticipatory guidance (birth to 1 year) (4) Discontinuation of alcohol use 1. Growth and development (5) Treatment for substance abuse/ a. Physical growth—height and weight addiction b. Motor development—early reflexive re- (6) Limit environmental/occupational sponses, gross and fine motor skills exposures that may be teratogenic c. Cognitive development—sensorimotor (7) Folic acid supplementation and language (8) Optimal glucose control for diabetics Aging 29

d. Psychosocial development—tem- 2. Skin—skin thinner and less elastic, thinning perament, emotional development, and graying of hair, increase in benign skin le- attachment sions, thick, ridged nails 2. Immunization schedule and health mainte- 3. Head, eyes, ears, nose, throat (HEENT) nance visits a. Arcus senilis—opaque ring at margins of 3. Nutritional needs—nutritional requirements, cornea with decreased tear production introduction of solid foods, weaning b. Increased cerumen, increased hair in ear 4. Safety promotion/injury prevention—Shaken canals Baby Syndrome, use of infant car seats, acci- c. Dry buccal mucosa with atrophy of sali- dent prevention, prevention of abduction vary glands; decreased taste sensation 4. Respiratory—rib cage less mobile, increased Â Aging anterior–posterior (AP) diameter 5. Cardiovascular/peripheral vascular—slower • Definition heart rate, increase in systolic BP, may have 1. Aging—process of growing older, regardless of carotid bruits, peripheral vessels distended chronologic age and tortuous 2. Senescence—mental and physical decline as- 6. Breasts—size and elasticity decrease sociated with the aging process 7. Abdomen—decreased muscle tone, may have less pain with abdominal pathology • Etiology/Incidence 8. Musculoskeletal—decrease in muscle mass, 1. Theories of aging—biologic, sociologic, and kyphosis developmental 9. Neurologic—slower reaction time, may have 2. By the year 2030, 25% of Americans will be decreased response to pain stimuli older than 65 years 10. Reproductive organs—sparse pubic hair, 3. Poverty—elderly women living alone or in eth- smaller labia, shorter, narrow vaginal canal nic minorities tend to be poorer than elderly with thin, smooth vaginal walls, shorter cervix, men; they are more likely to have only public smaller uterus and atrophy of the ovaries healthcare coverage or no insurance 4. Elder abuse and neglect—approximately 4% • Diagnostic tests and findings of elderly individuals are victims of abuse each 1. Most laboratory values not significantly year changed by aging in the absence of disease process • Signs and symptoms 2. Decreased glucose tolerance common in older 1. Dry skin, pruritus, delayed wound healing people—fasting glucose levels increase after 2. Decreased visual and hearing acuity age 50 3. Decreased taste and smell sensations 3. Mammography—American Cancer Society 4. Decreased exercise tolerance (ACS) and American College of Obstetricians 5. Decreased muscle strength and Gynecologists (ACOG) do not currently 6. Changes in sleep-wake cycle recommend a cut-off point for screening re- 7. Cognitive and memory changes lated to age

• Differential diagnosis—other medical conditions • Management—ACOG periodic (yearly or as appro- that may account for signs and symptoms priate) health examination recommendations for 1. Hypothyroidism women 65 years of age and older include: 2. Glaucoma, cataracts 1. Health history to include health status up- 3. Chronic cardiac and pulmonary disorders date, dietary assessment, physical activity, 4. Depression substance abuse, medications, abuse/neglect, 5. Alzheimer’s disease sexual practices 2. Physical examination—height and weight; • Physical findings blood pressure; examination of oral cavity, thy- 1. Anthropometric—percentage of total body fat roid, heart, lungs, breasts, abdomen, and skin; increases, waist-to-hip ratio increases, height pelvic and rectovaginal examination; other as may decrease due to thinning of cartilage indicated between vertebrae and changes in posture 3. Laboratory/diagnostic procedures—dipstick (kyphosis) urinalysis, mammography, and fecal occult blood test every year, cholesterol every 3 to 5 years, Pap test every 1 to 3 years, 30 Chapter 2 General Health Assessment and Health Promotion

sigmoidoscopy every 5 years or colonoscopy 3. Hepatic first pass effect—orally administered every 10 years, TSH every 3 to 5 years drug goes from GI tract through portal system 4. Other screening tests—visual acuity/glaucoma to liver before going to the general circulation; and hearing some metabolism of drug may occur as it is 5. Counseling—sexuality, diet, exercise, psy- taken up by hepatic microsomal enzymes chosocial concerns, cardiovascular risk factors, hormone replacement therapy, injury • Excretion prevention 1. Removal of drug from body via the kidneys, 6. Immunizations—Td booster every 10 years, intestines, sweat and salivary glands, lungs, or influenza vaccination annually, pneumococcal mammary glands vaccination once, zoster (shingles) vaccination 2. Urinary excretion—glomerular filtration, ac- once tive tubular secretion, and partial reabsorption 7. Pharmacologic considerations 3. Enterohepatic recirculation—some fat soluble a. Age-related decreases in hepatic metabo- drugs may be reabsorbed into the bloodstream lism and renal elimination, changes in from the intestines and returned to the liver body fat distribution, and central nervous system changes may have an impact on Pharmacodynamics (Study of Mechanism drug absorption, distribution, metabolism of Drug Action on Living Tissue) and excretion b. Polypharmacy—increased risk for adverse • Drug effects produced by reactions, drug interactions, noncompli- 1. Drug-receptor interaction ance, and increased cost with use of mul- 2. Drug-enzyme interaction tiple medications 3. Nonspecific drug interaction

Â Pharmacology • Affinity—propensity of a drug to bind itself to a given receptor site Pharmacokinetics • Efficacy—ability to initiate biologic activity as a • Absorption result of such binding 1. Movement of drug from site of entry into the body • Drug–response relationship 2. Affected by cell membranes, blood flow, drug 1. Plasma level profile—plasma concentration solubility, pH, drug concentration, dosage of a drug and therapeutic effectiveness over a form course of time; dependent on rates of absorp- 3. Bioavailability—percentage of active drug that tion, distribution, metabolism, and excretion is absorbed and available to the target tissue 2. Biologic half-life—time required to reduce by one half the amount of unchanged drug • Distribution that is in the body at the time equilibrium is 1. Movement of drug throughout body via circu- established latory system 2. Affected by permeability of capillaries and car- Adverse Reactions diac function 3. Plasma protein binding—drugs may attach • Predictable—may occur related to to proteins (mainly albumin) in the blood; 1. Age only unbound drug is active; as free drug is 2. Body mass excreted more of drug is released from binding 3. Gender to replace what is lost; competition for binding 4. Pathologic state sites by different drugs and hypoalbuminemia 5. Circadian rhythm can affect amount of free drug that is available 6. Genetic factors 4. Blood-brain barrier and placental barrier af- 7. Psychologic factors fect drug distribution • Unpredictable types include: • Metabolism 1. Drug allergy 1. Chemical inactivation of drug by conversion 2. Idiosyncrasy to a more water soluble compound that can be 3. Tolerance excreted from the body 4. Drug dependence 2. Chemical alterations are produced by microsomal enzymes mainly in the liver Questions 31

• Iatrogenic responses include: Â Questions 1. Blood dyscrasias 2. Hepatic toxicity Select the best answer. 3. Renal damage 4. Teratogenic effects 1. A 17-year-old client presents at the clinic with 5. Dermatologic effects the following reason for seeking care. “I have been sick for 3 days. I feel sick to my stomach and have diarrhea.” Which of the following Drug Interactions would be most appropriate to document as her • Antagonism—combined effect of two drugs is less reason for visit/chief complaint? than the sum of the drugs acting separately a. Flu-like symptoms b. Gastrointestinal distress • Summation—combined effect of two drugs equals c. “I feel sick to my stomach and have the sum of the individual effects of each drug diarrhea” d. Possible pregnancy, needs further evaluation • Synergism—combined effect of two drugs is greater than the sum of each drug acting 2. Which of the following would be considered a independently subjective assessment finding to be placed in the S section of SOAP format charting? • Potentiation—one drug increases the effect of the a. Motile trichomonads other drug b. Mucopurulent discharge c. Trichomoniasis vaginitis Drug Contraindications d. Vaginal itching

• Allergies, medical conditions, concurrent use of 3. Which of the following includes a pertinent neg- another drug, age, pregnancy, lactation may be ative that needs to be documented? drug contraindications a. 16-year-old female who has never been sexually active; no history of STDs • Food and Drug Administration (FDA) Pregnancy b. 25-year-old female with abdominal pain; no Safety Classifications nausea, vomiting, or diarrhea 1. Category A—studies indicate no risk to fetus c. 40-year-old female with depression; past 2. Category B—studies indicate no risk in ani- history of suicidal attempt mal fetus; information in pregnant women d. 60-year-old female with stress incontinence; unavailable no breast mass or nipple discharge 3. Category C—adverse effects reported in animal fetus; information in pregnant women is 4. Appropriate information to include in the review unavailable of systems section of the health history would 4. Category D—possible fetal risk in humans include: reported; in selected cases potential benefits a. Alert, cooperative, well groomed may outweigh risks for use of drug b. Had measles and chicken pox as a child 5. Category X—fetal abnormalities reported and c. Occasional loss of urine with coughing positive evidence of fetal risk in humans is d. Walks 2 miles a day for exercise available; these drugs should not be used in pregnancy 5. Which of the following would most appropriately be documented in the A section of SOAP charting format? Client Education a. Breast self-examination instructions provided • Purpose of drug, mechanism of action, b. Positive urine pregnancy test effectiveness c. Client states she would like to quit smoking d. Mucopurulent cervicitis • Benefits and risks 6. The bell of the stethoscope should be used when • Dosage and administration listening for: a. Bowel sounds • Major side-effects/adverse reactions b. Carotid bruits c. Lung sounds • Plan for follow-up d. S1 and S2 heart sounds 32 Chapter 2 General Health Assessment and Health Promotion

7. Evaluation of extraocular muscle movement c. Severe dehydration

(EOM) includes: d. Vitamin B12 deficiency a. Ophthalmoscopic examination 15. A client with an increased WBC count related to b. PERRLA evaluation infectious hepatitis would most likely have an c. Six cardinal fields of gaze elevated level of: d. Visual fields by confrontation a. Basophils 8. Which of the following constitutes a normal b. Eosinophils Weber test? c. Lymphocytes d. Neutrophils a. Able to hear whispered words at 1 to 2 feet b. Air conduction longer than bone conduction 16. Expected thyroid function test findings with c. Lateralization of sound to the ear being primary hypothyroidism include: tested a. Decreased TSH and decreased FT d. Sound heard equally in both ears 4 b. Decreased TSH and increased FT4

9. When auscultating lung sounds, the normal c. Increased TSH and decreased FT4

finding over most of the lung fields is: d. Increased TSH and increased FT4 a. Bronchial 17. A pregnant woman presents with a recent- b. Resonant onset rash. Which of the following laboratory c. Tympanic results would be reassuring that this is not likely d. Vesicular rubella? 10. Increased tactile fremitus would be an expected a. HAI titer of 1:10 at her initial visit 1 month finding with: earlier b. HAI titer of 1:128 at the current visit a. Asthma c. Increased IgG antibody levels at the current b. Emphysema visit c. Lobar pneumonia d. Increased IgM antibody levels at the current d. Pleural effusion visit 11. The sound heard over the cardiac area if there is 18. A client who had hepatitis B 6 months ago cur- pericarditis is mostly likely to be a/an: rently has no symptoms but has a positive test a. Diastolic murmur for HbsAg. This most likely indicates that she: b. Fixed split S 2 a. Has immunity to future infection c. Friction rub b. Has persistent active infection d. Increased S 4 c. Is a chronic carrier of hepatitis B 12. Which of the following is an abnormal abdom- d. Is in the early stage of reinfection inal examination finding in an adult? 19. A false negative TB test may be the result of: a. Abdominal aorta 2.5 cm in width a. Dormant infection b. Liver border nonpalpable b. Immunosuppression c. Liver span 8 cm at the right MCL c. Intradermal injection d. Splenic dullness at the left anterior axillary d. Prior BCG vaccination line 20. An individual with cholecystitis would most likely 13. One of the cranial nerves for which you would have a/an: test both motor and sensory function is: a. Decreased alkaline phosphatase a. CN II—optic nerve b. Decreased indirect bilirubin b. CN V—trigeminal nerve c. Increased albumin level c. CN X—vagus nerve d. Increased direct bilirubin d. CN XI—spinal accessory nerve 21. Measuring waist circumference is most appro- 14. A client with an Hgb of 10.2 g/dL and an RBC priate when the client’s BMI places her in which indices indicating both microcytosis and hypo- of the following categories: chromia most likely has: a. Underweight a. Folic acid deficiency b. Normal weight b. Iron deficiency Questions 33

c. Overweight c. Discriminatory sensation tests d. Extreme Obesity d. Romberg test for balance 22. A 58-year-old woman who is not on estrogen 28. A healthy 70-year-old female is at the clinic in therapy gets an average daily dietary calcium November for her annual examination. She had intake of 500 mg. According to National Insti- influenza vaccination 1 year ago. She had a tute of Health recommendations, she should be pneumococcal vaccination and a tetanus booster advised to take a daily supplement of at least: vaccination 10 years ago. What vaccinations should be given at the current visit? a. 500 mg b. 700 mg a. Influenza only c. 1000 mg b. Influenza and pneumococcal d. 1500 mg c. Influenza and tetanus booster d. Influenza, pneumococcal, and tetanus 23. A 53-year-old woman is at the clinic for her booster annual examination. She had the following tests 1 year ago—fecal occult blood test and sigmoid- 29. Client education concerning the use of bupro- oscopy. Three years ago she had a normal lipid pion hydrochloride for smoking cessation should profile and fasting blood glucose. She has never include: had a TSH level. If she has no relevant risk factors a. Discontinue smoking prior to initiation of she should have the following tests done or this medication ordered at her current visit: b. The medication should not be used for more a. Lipid profile, fasting blood glucose, and fecal than 8 weeks occult blood test c. Initiate the medication at least 1 week prior b. Lipid profile, TSH, and sigmoidoscopy to smoking cessation c. Fasting blood glucose and fecal occult blood d. Side-effects may include drowsiness and test weight gain d. Fasting blood glucose, fecal occult blood 30. Which of the following statements regarding test, and TSH influenza vaccination during pregnancy is true? 24. Appropriate management for a 45-year-old a. Influenza vaccination should only be given if white woman who has no diabetes risk factors the woman has health problems placing her and no symptoms of diabetes with a fasting at high risk for complications with influenza glucose of 130 mg/dL would include: b. Influenza vaccination may be safely given in a. Inform client she has impaired glucose any trimester of pregnancy tolerance c. Intranasal influenza vaccine is recommended

b. Order HbA1c level for pregnant women to reduce chances for c. Repeat glucose testing on another day side-effects d. Repeat glucose screening in 3 years d. Influenza vaccination is contraindicated during pregnancy 25. Which of the following pharmacokinetic changes could decrease the effect of a medication? 31. The drug category in which adverse effects have been reported in an animal fetus and informa- a. Decrease in plasma protein binding tion in pregnant women is unavailable is: b. Increase in hepatic first pass effect c. Increase in enterohepatic recirculation a. Category B d. Increase in bioavailability b. Category C c. Category D 26. “One plus one equals three” best describes d. Category X which of the following drug interactions? 32. Which of the following heart sounds may be a. Antagonism a normal finding for a woman in the third tri- b. Potentiation mester of pregnancy? c. Summation d. Synergism a. Diastolic murmur b. Fixed split S 27. Tests for cerebellar function include: 2 c. S3

a. Deep tendon reflex evaluation d. S4 b. Short-term memory evaluation 34 Chapter 2 General Health Assessment and Health Promotion

33. Pelvic findings on examination of a 22-year-old c. 2 months and 6 months after the initial dose nulliparous woman are uterus 7 cm in length and d. 3 months and 12 months after the initial ovaries 3 cm × 2 cm × 1 cm. These findings are dose consistent with: 40. Which of the following vaccinations should a. Enlarged uterus and enlarged ovaries not be given to an individual who is b. Enlarged ovaries and normal size uterus immunocompromised? c. Enlarged uterus and normal size ovaries a. Hepatitis A d. Normal size uterus and normal size ovaries b. Pneumococcal 34. A laboratory test finding of increased immature c. Rubella neutrophils (shift to the left) is consistent with d. Varicella a/an: 41. An abnormal finding on ophthalmoscopic exami- a. Acute bacterial infection nation would be: b. Acute viral infection a. Arterioles smaller than veins c. Allergic reaction b. Optic disk that is yellow d. Chronic bacterial infection c. Presence of a red reflex 35. An elderly woman has had gastroenteritis with d. Tapering of the veins vomiting and diarrhea for the past 3 days. Her 42. When examining the cervix of a 20-year-old mucous membranes appear dry, and she says she female, you note that most of the cervix is pink has not urinated yet today. Expected laboratory but there is a small ring of dark red tissue sur- test findings related directly to her current condi- rounding the os. This is most likely: tion might include: a. An endocervical polyp a. Decreased urine specific gravity b. Due to cervical dysplasia b. Decreased hematocrit c. Due to cervical infection c. Increased blood glucose d. The squamocolumnar junction d. Increased blood urea nitrogen 43. The laboratory test that is done for definitive 36. The blood type in which an individual has no diagnosis of sickle cell disease is: antigens on their RBCs is: a. Hgb electrophoresis a. AB+ b. Peripheral blood smear b. AB– c. RBC indices c. O+ d. Sickle cell preparation d. O– 44. A woman who is currently pregnant, has had 37. A woman who describes finding her partner two full-term deliveries and one abortion would sexually attractive but is not able to maintain be considered: sufficient sexual excitement and lubrication during sexual activity has: a. Gravida 2 Para 2 b. Gravida 3 Para 2 a. Hypoactive sexual desire disorder c. Gravida 3 Para 3 b. Sexual arousal disorder d. Gravida 4 Para 2 c. Sexual orgasmic disorder d. Vaginismus 45. The best position for palpating the axilla is with the woman: 38. Authorities recommend that African Americans begin regular screening at an earlier age than a. Lying down with her arm above the head on the general population recommendations for: the side you are examining b. Lying down with her arm at her side on the a. Breast cancer side you are examining b. Colon cancer c. Sitting up with her arm raised above her c. Diabetes head on the side you are examining d. Thyroid disease d. Sitting up with her arm down on the side 39. The second and third doses of the human papil- you are examining loma virus (HPV) vaccination should be given: a. 1 month and 3 months after the initial dose b. 2 months and 3 months after the initial dose Bibliography 35

46. Which of the following would be considered a Â Answers positive PPD result? a. General population—5 mm induration â 1. c 27. d b. General population—10 mm induration â 2. d 28. d c. Moderate-risk population—5 mm induration â 3. b 29. c d. High-risk population—5 mm induration â 4. c 30. b â 5. d 31. b 47. Abnormal findings on a urinalysis would include: â 6. b 32. c a. pH 5.0 â 7. c 33. d b. Specific gravity 1.5 â 8. d 34. a c. WBCs 3 per HPF â 9. d 35. d d. Protein 4 mg/dL 10. c 36. d 48. Which of the following types of vaccines should 11. c 37. b not be given during pregnancy? 12. d 38. c a. Bacterial vaccines 13. b 39. c b. Inactivated virus vaccines 14. b 40. d c. Live attenuated virus vaccines 15. c 41. d d. Immunoglobulins 16. c 42. d 49. Which of the components of the PLISSIT model 17. a 43. a would best describe instructing a couple on the 18. c 44. d use of water soluble lubrication for dyspareunia 19. b 45. d caused by vaginal dryness? 20. d 46. d a. Permission giving 21. c 47. b b. Limited information 22. b 48. c c. Specific instructions 23. c 49. c d. Intensive therapy 24. c 50. b 50. Good dietary sources for folic acid include: 25. b 51. b 26. d 52. b a. Chicken b. Dried beans c. Egg yolks Â Bibliography d. Milk 51. Expected physical findings with aging include: American Cancer Society. (2009). Can breast cancer be found early? Retrieved on July 10, 2009 from www. a. Decrease in total body fat cancer.org. b. Increase in benign skin lesions American College of Obstetricians and Gynecologists. c. Increase in heart rate (2009). Routine screening for hereditary breast and d. Increased response to pain stimuli ovarian cancer recommended. ACOG News Release, 52. Which of the following would not be an March 20, 2009. expected pelvic examination finding in a 70-year- American College of Obstetricians and Gynecologists. old woman? (2009). Cervical cytology screening. ACOG Practice Bulletin, 109, 1–12. a. Narrow vaginal canal American Diabetes Association. (2009). Position state- b. Palpable ovaries ment: Diagnosis and classification of diabetes melli- c. Small uterus tus. Diabetes Care, 32 (suppl 1), S62–S67. d. Thin vaginal walls Association of Reproductive Health Professionals. (2005). Women’s sexual health in midlife and beyond. ARHP Clinical Proceedings, May 2005, 3–27. Bickley, L. (2009). Bates’ guide to physical examination and history taking (10th ed.). Philadelphia, PA: Lip- pincott, Williams, & Wilkins. 36 Chapter 2 General Health Assessment and Health Promotion

Branson, B., Handsfield, H., Lampe, M., Janssen, R. Saslow, D., Hannan, J., Osuch, J. et al. (2004). Clinical et al. (2006). Revised recommendations for HIV test- breast examination: Practical recommendations for ing of adults, adolescents, and pregnant women in optimizing performance and reporting. CA Cancer healthcare settings. MMWR, 55(RR14), 1–17. Journal for Clinicians, 54, 327–344. Centers for Disease Control (CDC). (2008). Smok- Saslow, D., Runowicz, C., Solomon, D. et al. (2002). ing prevalence among women of reproductive age, American Cancer Society guidelines for the early de- United States—2006. MMWR, 57(31), 849–852. tection of cervical neoplasia and cancer. CA Cancer Centers for Disease Control (CDC). (2008). Ciga- Journal for Clinicians, 52(6), 342–362. rette smoking among high school students, United Seidel, H., Ball, J., Dains, J., & Benedict, G. (2006). Mos- States—1991–2007. MMWR, 57(25), 689–691. by’s guide to physical examination (6th ed.). St. Louis: Chernecky, C., & Berger, B. (2008). Laboratory tests and Mosby, Inc. diagnostic procedures (5th ed.). St. Louis: Saunders Siegel, J., Rhinehart, E., Jackson, M., Chiarello, L., & Elsevier. Healthcare Infection Control Practices Advisory Com- Ferri, F. (2009). Ferri’s clinical advisor 2009: Instant di- mittee (2007). 2007 guideline for isolation precautions: agnosis and treatment. Philadelphia, PA: Mosby Preventing transmission of infectious agents in health- Elsevier. care settings. Giger, J., & Davidhizer, R. (2004). Transcultural nurs- Smith, R., Cokkinides, V., & Brawley, O. (2008). Can- ing assessment and intervention (4th ed.). St. Louis: cer screening in the United States: A review of cur- Mosby, Inc. rent American Cancer Society guidelines and cancer Hackley, B., Kriebs, J., & Rousseau, M. (2007). Primary screening issues. CA Cancer Journal for Clinicians, 58, care of women: A guide for midwives and women’s 161–179. health providers. Sudbury, MA: Jones and Bartlett. Smith, R., Saslow, D., Sawyer, K. et al. (2003). American National Cholesterol Education Program. (2001). Third Cancer Society guidelines for breast cancer screen- report of the expert panel on detection, evaluation, ing: Update 2003. CA Cancer Journal for Clinicians, and treatment of high blood cholesterol in adults 53(3), 141–169. (adult treatment panel III). Bethesda, MD: National Tharpe, N., & Farley, C. (2009). Clinical practice guide- Heart, Lungs and Blood Institute. lines for midwifery and women’s health (3rd ed.). Sud- National Heart, Lung, and Blood Institute (NHLBI). bury, MA: Jones and Bartlett. (2008). How are overweight and obesity diagnosed. The Advisory Committee on Immunization Practices. Retrieved on April 11, 2010 from www.nhlbi.nih.gov/ (2009). Recommended adult immunization schedule health/dci/Diseases/obe/obe_diagnosis.html. United States. Atlanta: Department of Health and National Heart, Lung, and Blood Institute (NHLBI). Human Services—Centers for Disease Control and (2003). The seventh report of the Joint National Com- Prevention. mittee on Prevention, Detection, Evaluation, and US Department of Health and Human Services. (2008). Treatment of High Blood Pressure. Washington, DC: Physical activity guidelines for Americans. Washing- National Institute of Health. ton, DC: USDHHS. National Institute of Arthritis, Musculoskeletal, and US Department of Health and Human Services. (2005). Skin Diseases. (2009). Nutrition and bone health. Dietary guidelines for Americans. Washington, DC: Washington, DC: National Institute of Health. USDHHS. National Osteoporosis Foundation. (2008). Clinician’s Varney, H., Kriebs, J., & Gegor, C. (2004). Varney’s mid- guide to prevention and treatment of osteoporosis. wifery (4th ed.). Sudbury, MA: Jones and Bartlett. Washington, DC: National Osteoporosis Foundation. Wynne, A., Woo, T., & Olyaei, A. (2007). Pharmacothera- Saslow, D., Boetes, C., Burke, W., Harms, M. et al. (2007). peutics for nurse practitioner prescribers (2nd ed.). American Cancer Society guidelines for breast cancer Philadelphia, PA: F. A. Davis. screening with MRI as an adjunct to mammography. CA Cancer Journal for Clinicians, 57, 75–89. 3 Women’s Health

Beth M. Kelsey Anne A. Moore

¶ GYNECOLOGY (NORMAL) a. Vulva—visible external structures bor- dered by symphysis pubis anteriorly, UÊ >ÌÞÊ>`Ê« ÞÃ}ÞÊvÊÀi«À`ÕVÌÛiÊÀ}>Ã buttocks posteriorly, and thighs laterally; 1. Breast—located on anterior chest; a modi- develops as a secondary sex characteristic fied sweat/mammary gland responsible for under the influence of estrogen during lactation puberty a. Body—composed of lobes, lobules, and (1) Mons pubis—fatty tissue prominence alveoli overlying symphysis pubis, covered (1) Lobes—15 to 20 each breast; forms by coarse hair inverted in a triangular circle ending in Tail of Spence; located pattern in the upper outer quadrant of each (2) Labia majora—two longitudinal folds breast terminating in the axillary area of adipose tissue extending from the (2) Lobules—extend from lobes terminat- mons pubis downward enclosing four ing in alveoli; network of ducts extend structures: from lobules forming lactiferous si- (a) Labia minora—thin folds inside/ nuses that direct milk toward nipple; parallel to the labia majora; forms interlobule breast tissue composed of prepuce anteriorly, encloses the fat vestibule, and terminates in the Î®Ê ÛipV>Ìi`Ê>ÌÊÌiÀÕÃÊvÊL- fourchette ules; responsible for milk production (b) Clitoris—small erectile body of (4) Unique proliferation occurs under tissue; abundant supply of sen- influence of estrogen during puberty sory nerve endings; rich vascular b. Nipple—composed of pigmented erectile supply; important for female tissue, areola, and Montgomery’s glands; sexual response terminus into which lactiferous sinuses (c) Vestibule—contains urethral/ secrete milk vaginal openings, hymen, Skene’s £®Ê Ài>pVÀVÕ>ÀÊ«}iÌi`Ê>Ài>ÊÌ >ÌÊ glands, Bartholin’s glands surrounds the nipple (d) Perineum—located between the (2) Montgomery’s glands—sebaceous fourchette anteriorly and the anus glands that circle the nipple located posteriorly within the areola b. Pelvic musculature—consists of perineal 2. External genitalia—composed of the vulva and muscles and pelvic floor muscles its associated structures (1) Perineal muscles

37 38 Chapter 3 Women’s Health

(a) Bulbocavernosus—surrounds va- (2) Uterine body—extends upward from gina acting as weak sphincter cervix and lies in the pelvic cavity; (b) Ischiovernosus—surrounds contains cavity or potential space that clitoris; responsible for clitoral can accommodate pregnancy erection (a) Located between bladder and (c) Superficial/deep transverse rectum perineal muscles—converge with (b) Averages 8 cm in length, 5 cm in urethral sphincter width, 3 cm in thickness (d) External anal sphincter (c) Composed externally of thick my- (2) Pelvic floor muscles ometrial muscles (myometrium) (a) Levator ani—pubococcygeus, il- (d) Composed internally of columnar iococcygeus, and ischiococcygeus epithelium (endometrium); shed muscles during menstruation (b) Pubococcygeus—pubovaginalis, (e) Fundus—top portion where fal- puborectalis, and pubococcygeus lopian tubes insert proper (f) Isthmus (lower uterine 3. Internal pelvic structures—develop primarily segment)—immediately superior as a result of stimulation by estrogen initiated to cervix during puberty; structures reach their adult (g) Corpus—main body size/appearance by approximately age 16 c. Fallopian tubes—ciliated oviducts that a. Vagina—muscular/membranous canal transport ova from the ovaries to the that connects the external genitalia to the uterus uterus (1) Length—approximately 10 cm (1) Length—approximately 7 cm anterior, (2) Interstitial portion—within uterus 10 cm posterior (3) Isthmus—main body (2) Stratified squamous epithelium (4) Ampulla—adjacent to the ovary; re- (3) Rugae—corrugated sidewalls; al- ceives ova at ovulation lows for distention during coitus and (5) Fimbriated ends/Infundibulum childbirth d. Ovary—pair of endocrine organs located (4) pH—acidic due to prevalence of lac- at the end of fallopian tube tobacilli; due to influence of estrogen (1) Responsible for secretion of steroid initiated during puberty hormones—estrogen/progesterone b. Uterus—pear shaped organ that is com- (2) Approximately 3 cm 3 2 cm 3 1 cm posed of the following: (3) Cyclic release of ovum (1) Cervix—round, firm terminus to the uterus that protrudes into the vagina • Puberty/Adolescence—adolescence defined (a) Os—opening in cervix that pro- means “to grow up”; puberty denotes the biology vides access to the uterine cavity; of adolescence, beginning around age 9 and culmi- external os is proximal to the va- nating in development of regular menstrual cycles gina, internal os is proximal to the 1. Hormonal changes—begin as hypothalamic- uterine cavity pituitary-ovarian axis matures (b) Squamocolumnar junction— a. Gonadotropin-releasing hormone juncture of the squamous epithe- (GnRH)—released from hypothalamus lium covering the cervical body b. Gonadotropins—follicle stimulating hor- (portio) and the columnar epithe- mone (FSH) and luteinizing hormone (LH) lium lining the endocervix released from anterior pituitary gland in (c) Transformation zone—site of response to GnRH original squamocolumnar junc- c. Estrogen—primarily released by ovary in tion (established during gesta- response to FSH; results in development tion) and the current site; area of secondary sex characteristics and ulti- where squamous metaplasia mately in menstruation occurs 2. Physical changes—tanner staging–physical (d) Squamous metaplasia—process characteristics of breast/pubic hair develop- whereby columnar cells of the en- ment/distribution that delineate progressive docervix are replaced by mature advancement of physiologic maturity squamous epithelium Gynecology (Normal) 39

a. Growth spurt—girls may grow from 6 to (a) Mons and labia majora increase 11 cm taller; greatest height velocity oc- in size curs around age 12 or just prior to onset of (b) Clitoris enlarges menses (6) Internal pelvic structures b. Thelarche—breast development; begins (a) Vagina lengthens to approxi- with breast budding around age 9, pro- mately 10 cm; pH less than 4.5; gresses to conical shape followed by fully rugae appear developed breast with round contour (b) Uterus—proliferative endome- around age 17 trium; thin, clear cervical mucus c. Adrenarche—growth of pubic and axillary (c) Ovaries—follicular development; hair; results from secretion of adrenal an- approximately 3 cm long, 2 cm drogens; usually starts after breast devel- wide, and 1 cm thick opment begins b. Progesterone—steroid hormone produced d. Menstruation—results from shedding of by ovarian corpus luteum and conversion estrogen primed endometrium; average of adrenal pregnenolone/pregnenolone age is 12.5 years following peak height sulfate; luteal phase of menstrual cycle velocity (1) Uterus—secretory endometrium; 3. Psychosocial/cultural changes thickens cervical mucus a. Developmental tasks (2) Ovary—supplied by corpus luteum; (1) Establish independence—struggle level of 3 ng/mL or greater indicates with authority vs autonomy ovulation (2) Experimentation—means of achieving (3) Breast—subcutaneous fluid retention cognitive development c. Prostaglandin—20-carbon molecules de- (3) Develop self-esteem rived from arachidonic acid through ac- (4) Establish peer relationships tion of prostaglandin synthetase enzymes b. Cognitive development (1) Increased production by the uterus as (1) Progression from concrete operational with primary dysmenorrhea thinking (7 to 12 years) to formal logi- (2) Increases uterine activity resulting in cal operations (12 years and older) ischemia (2) True logical thought and manipula- d. Follicle stimulating hormone—gonadotro- tion of abstract concepts emerge from pin; released by anterior pituitary gland in 12 to 16 years response to GnRH from hypothalamus (1) Ovary—stimulates follicular growth • Reproductive years (2) Positive/negative feedback from ovar- 1. Effect of hormones ian hormones determines level a. Estrogen—steroid hormone responsible e. Luteinizing hormone—gonadotropin, for development of secondary sex charac- released by anterior pituitary gland in re- teristics; produced by ovarian follicles, ad- sponse to GnRH from hypothalamus renal cortex, corpus luteum; predominant (1) “Surge” responsible for physical act of in follicular phase of menstrual cycle ovulation (1) Estradiol—most potent; derived from (2) Induces steroidogenesis and increases ovarian follicles, particularly domi- synthesis of androgens by the internal nant follicle; primary estrogen of re- cells of ovary productive age (3) Promotes follicular atresia in non- (2) Estrone—estrogen of menopause; dominant follicles converted from androstenedione pro- (4) Promotes final growth of graafian duced by adrenal gland and ovarian follicle stroma (5) Promotes luteinization of granulosa (3) Estriol—least potent; estrogen of preg- cells nancy; derived from conversion of f. Prolactin—anterior pituitary gland estrone and estradiol in liver, uterus, hormone placenta, and fetal adrenal gland (1) Progressive release during pregnancy (4) Breasts develop fully to round adult (2) Stimulates synthesis of milk proteins contour—development/growth of in mammary tissue ductal system, lobular, alveolar growth (3) Stimulates epithelial growth in breast (5) External genitalia during pregnancy 40 Chapter 3 Women’s Health

g. Gonadotropin-releasing hormone (d) Thickened cervical mucus (GnRH)—released from hypothalamus (e) Maintained increase in BBT (1) Stimulates anterior pituitary gland to (f) If no pregnancy, CL regresses and release FSH/LH progesterone decreases (2) Pulsatile release (g) Ends with onset menses h. Adrenal hormones—adrenal cortex b. Uterine cycle—defined by endometrial (1) Cortisol—metabolizes proteins, car- changes bohydrates, fats (1) Proliferative phase—estrogen (2) Aldosterone—regulates sodium and influence potassium; decreases sodium/ (a) Endometrium grows/thickens increases potassium secretion by (b) Lasts approximately 10 days from kidney end of menses to ovulation (3) Androstenedione—converted to es- (2) Secretory phase—progesterone trone in adipose tissue influence (4) Testosterone—can be converted to (a) Average 12 to 16 days estradiol (b) From ovulation to menses 2. Menstrual cycle—timed from beginning of one (c) Endometrial hypertrophy menstrual bleed to beginning of consecutive (d) Increased vascularity bleed; average 28 days plus or minus 2 days; (e) Favorable for implantation of fer- duration 4 to 6 days plus or minus 2 days; vol- tilized ovum ume average 40 cc (3) Menstruation—declining progester- a. Ovarian cycle—defined by ovarian one from CL changes (a) Endometrium undergoes involu- (1) Follicular phase tion, necrosis, sloughing (a) Begins day 1 menses (b) 3 to 6 days average (b) Variable length (time frame) 3. Breast health (c) Increased FSH/LH a. Breast self-examination (BSE)

(d) Increased E2 from dominant (1) American Cancer Society (ACS)—be- follicle ginning in their 20s, inform of benefits (e) Decreased FSH and limitations of BSE and provide (f) LH surge (peak 10 to 12 hours be- instruction for women who choose fore ovulation) to do BSE; it is acceptable for women (g) Thin cervical mucus to choose not to do BSE or to do BSE (2) Ovulation irregularly (a) Prostaglandins and proteolytic (2) American College of Obstetricians and enzymes break down the follicular Gynecologists (ACOG)—adult women wall should perform BSE monthly (b) Follicle ruptures releasing oocyte (3) Studies indicate breast self-examination (c) Occurs 32–44 hours after LH surge alone does not reduce number of begins cancer deaths; it should not be used (d) Maximal production of thin, in place of clinical breast examination stretchy, cervical mucus (spinn- and mammography (National Cancer barkeit—refers to ability of cer- Institute) vical mucus to be “stretched” (4) Inspection—in front of mirror between examining fingers; in- (a) Hands pressed on hips creased stretch equals increased (b) Observe for symmetry, dimpling, influence of estrogen) contour (e) Peak sexual desire (5) Palpation (f) Increase in basal body tempera- (a) In upright position with arm ture (BBT) of 0.2 to 0.5°F slightly raised, palpate the under- (3) Luteal phase arm area on each side (a) Begins after ovulation occurs (b) Reclining with pillow under (b) Approximately 14 days plus or mi- shoulder; arm raised nus 2 days in length (c) Pads of three middle fingers used, (c) Corpus luteum (CL) formed overlapping dime sized circular from ruptured follicle; secretes motions at three levels of pressure progesterone—peak 7 to 8 days over entire area of both breasts postovulation Gynecology (Normal) 41

(d) Use vertical up and down pattern nonreproductive status; 2–8 years before across entire chest wall; clavicle to menopause until 1 year after last period inframammary fold, sternum to c. Perimenopause—another term for posterior axillary line climacteric b. Screening mammography d. Postmenopause—phase of life following (1) Age 40 to 50 menopause (a) American Cancer Society (ACS)— e. Premature menopause (premature ovarian annual screening failure)—cessation of menses before (b) National Cancer Institute (NCI)— age 40 screening every 1 to 2 years/con- 2. Physiology sult with provider a. As climacteric begins, the rhythmic ovar- (c) Strong family history (maternal ian and endometrial responses of the grandmother, mother, sister) may menstrual cycle decline and eventually warrant earlier/more frequent stop screening b. Number of responsive follicles decreases (2) Older than age 50—annual screening with resultant decreased production of (3) Dense breast tissue in younger estradiol throughout climacteric women limits reliability c. With decreasing estradiol, FSH levels (4) 10 to 15% false negative rate for detec- increase tion of malignancies d. At the end of the climacteric, ovary con- c. BRCA1/BRCA2-breast cancer gene testing tains no follicles and endometrium atro- (1) 5 to 10% of breast cancer is hereditary phies so that reproductive capability is (2) Women with mutated BRCA1 gene terminated have 80% risk of breast cancer by e. After menopause, estrone becomes princi- age 65 pal estrogen (3) Indicated if f. Estrone produced through aromatization (a) Strong family history—first/ of androstenedione; androstenedione is second generation female an androgen produced by adrenal cortex relatives and ovarian stroma; converted to estrone (b) Ashkenazic Jewish descent in peripheral fat cells (4) Not cost effective as general screening g. After menopause, both FSH and LH levels d. Clinical breast examination—see General are elevated Health Assessment/Health Promotion h. Generally rely on cessation of menses, chapter for detailed information hypoestrogenic symptoms, age, and con- 4. Psychosocial/cultural factors sistently elevated FSH for diagnosis of a. Menstruation menopause (1) Viewed as unclean by some cultures 3. Laboratory findings (2) Intercourse may be prohibited with a. FSH—greater than 40 mIU/mL any vaginal bleeding b. LH—3-fold elevation after menopause (3) View of individual influenced by (20–100 mIU/mL) family/community/society c. Estradiol—less than 20 pg/mL b. Growth/development 4. Possible menstrual changes in climacteric (1) Influenced by culture/ethnicity a. No change (2) Influenced by nutritional status b. Oligomenorrhea/Polymenorrhea—cycles c. Health promotion behaviors—priori- shorter or longer than usual tized by culture/society/socioeconomic c. Hypomenorrhea/Hypermenorrhea— conditions bleeding lighter/shorter or heavier/longer than usual • Menopause d. Metrorrhagia—irregular intervals, amount 1. Definitions variable a. Menopause—cessation of menses; av- 5. Physical changes erage age in US is 51 years; genetically a. Reproductive organs predetermined; confirmed after 12 con- (1) Labia—decrease in subcutaneous fat secutive months without a period and tissue elasticity b. Climacteric—term used to describe (2) Vagina the physiologic changes associated with the change from reproductive to 42 Chapter 3 Women’s Health

(a) Thinning of epithelium; de- f. Generally cease within 2–3 years after creased rugae, increase in pH of menopause greater than or equal to 5.0 7. Cardiovascular system effects (b) May have pruritus, leukorrhea, a. Lipid levels—increase in low-density lipo- friability, increased susceptibility proteins (LDL), very low-density lipopro- to infection teins (VLDL), and triglycerides, possible (c) May have dyspareunia decrease in high-density lipoproteins (3) Cervix—decrease in size, os may be- (HDL) come flush with vaginal walls, may b. Regulation of clotting processes—increase become stenotic in certain fibrinolytic and procoagulation (4) Uterus and ovaries—decrease in factors size and weight; ovaries usually not c. Vasoactive substances—increase in en- palpable dothelin and decrease in angiotensin b. Urinary tract converting enzyme (vasoconstrictors), (1) Decreased muscle tone—urethra and increase in nitric oxide and decrease in trigone area of bladder prostacyclin (vasodilators) (2) Atrophic changes in urethra and peri- d. Extent of impact of decreased estrogen urethral tissue—stress incontinence levels on cardiovascular disease not de- may occur finitively established (3) Hypoestrogenic effects in trigone area; 8. Alterations in mood lowered sensory threshold to void— a. Majority of women do not have psy- sensory urge incontinence may occur chological problems attributable to (4) Urinary urgency, frequency, and dys- menopause uria due to atrophic changes in ure- b. Depression in menopause often related to thra and periurethral tissue history of previous depression c. Breasts—reduction in size and flattened c. Depression/irritability may be related to appearance; decrease in glandular tissue sleep disturbances caused by hot flashes d. Skin d. Perceived health shown to be a major (1) Thinning/decreased activity of seba- factor related to depression in perimeno- ceous and sweat glands pausal women; individual characteristics (2) Hyperpigmentation/ and self-perception appear to be impor- hypopigmentation tant determinants of each woman’s experi- (3) Scalp, pubic, and axillary hair be- ence of the climacteric comes thinner and drier e. More research is needed to establish hor- e. Bone integrity monal influences on mood changes that (1) Increased bone loss associated with occur during the perimenopause decrease in estrogen 9. Cognitive function (2) See section on Osteoporosis in Nongy- a. Memory impairment may be indirectly necological Problems chapter for related to decreased estrogen secondary to more information hot flashes and sleep disturbance 6. Vasomotor symptoms—hot flashes b. WHIMS trial—risk of dementia increased a. Observed in 75% of women during in healthy women aged 65 to 79 years us- climacteric ing estrogen or estrogen with progester- b. Mechanism responsible not known; one therapy gonadotropin-related effect on the cen- c. Unclear how estrogen or estrogen with tral thermoregulatory function of the progesterone therapy impacts cognitive hypothalamus (measurable increase in function in younger menopausal women body surface heat and decrease in core 10. Sexuality temperature) a. Diminished genital sensation, less vaginal c. Sudden feeling of warmth followed by vis- expansion, and decreased vasocongestion ible redness of upper body and face may cause some changes in orgasm expe- d. May be associated with profuse sweating rience—increased time to reach orgasm, and palpitations shorter duration of orgasm, decreased e. May awaken during the night, leading to strength of orgasmic contractions insomnia, sleep disturbance, cognitive b. Freedom from fear of pregnancy, freedom (memory), and affective (anxiety) disor- from contraceptives, and increased pri- ders with loss of REM sleep vacy as children leave home may increase sexual enjoyment Gynecology (Normal) 43

c. Dyspareunia, loss of partner, medications, are present (American Academy of and chronic illness may affect sexual de- Ophthalmology) sire and activity (10) Other as determined by risk factors 11. Health assessment/Health promotion d. Immunizations—see section on immuni- a. Health history zations in General Health Assessment and (1) Family and personal history—focus Health Promotion chapter on risks for cancer, heart disease, e. Counseling and education osteoporosis (1) High-risk behaviors (2) High-risk behavior evaluation—smok- (2) Nutrition—see section on nutrition ing, alcohol, drugs, STD/HIV risks in General Health Assessment and (3) Menstrual history—focus on irregular Health Promotion chapter bleeding problems (3) Self-examination—breasts, skin, vulva (4) Nutrition and exercise assessment (4) Physical activity—see section on (5) Psychosocial assessment—sexuality, physical activity in General Health stressors, support system, domestic Assessment and Health Promotion violence chapter b. Physical assessment (6) Injury prevention—seat belts, safety (1) Blood pressure helmets for bike riding, smoke detec- (2) Height and weight tors, fall prevention (3) BMI (7) Sexuality (4) Complete physical examination (8) Management of menopausal c. Screening tests symptoms (1) Pap test every 1–3 years (ACOG, ACS, (9) Benefits and risks of hormone therapy North American Menopause Society (HT) [NAMS]) (10) Health maintenance checkup (2) Rectal examination and stool for oc- schedule cult blood annually beginning age 50 f. Contraception for women over 40 (ACS, NAMS) (1) Continue contraception until FSH (3) Sigmoidoscopy age 50 and then every level indicates no longer fertile or no 3–5 years or colonoscopy every 10 menses for 1 year years, or double contrast barium en- (2) Options ema every 5–10 years (ACS, NAMS) (a) Combination (estrogen- (4) Mammography every year starting at progestin) contraception age 40 (ACS, NAMS) i. Safe option for nonsmoking, (5) Cholesterol with HDL every 5 years nonobese, healthy perimeno- beginning at age 20; more frequent pausal women and additional lipid tests as needed ii. Noncontraceptive benefits (National Cholesterol Education Pro- may be especially attrac- gram [NCEP] of the National Heart, tive to the perimenopausal Lung, and Blood Institute) woman—relief of vasomo- (6) Plasma glucose every 3 years if age 45 tor symptoms, menstrual years or older and for younger women regulation with risk factors (American Diabetic (b) Progestin-only contraception also Association, NAMS) safe option (7) Thyroid function/TSH every 3–5 (c) Approaches used in deciding years for age 65 years and older; begin when to discontinue hormonal screening earlier if presence of auto- contraception include reach- immune condition or strong family ing age 55 (90% of women have history of thyroid disease (ACOG) reached menopause by this age) (8) Hearing screening for 65 years and vs two FSH levels while off of hor- older monal contraception and using a (9) Screening for visual acuity and glau- nonhormonal contraceptive coma by ophthalmologist every 2–4 (d) Intrauterine contraception (IUC) years from age 40–64 and every 1–2 i. Long lasting, effective contra- years beginning at age 65; earlier and ceptive option more frequent screening if risk factors ii. Levonorgestrel IUS (LNG IUS) may also be therapeutic for 44 Chapter 3 Women’s Health

perimenopausal women with g. Regimen options heavy bleeding (1) 0.625 mg conjugated estrogen or (e) Barrier methods are acceptable equivalent is dosage shown to prevent options osteoporosis in 90% of postmeno- (f) Sterilization—most prevalent pausal women contraceptive method among (2) 10–14 days each month of 10 mg of married women in the US medroxyprogesterone acetate (MPA) (g) Fertility awareness methods less or equivalent or daily doses of 2.5–5.0 effective during perimenopause mg recommended for prevention of with irregular menstrual cycles endometrial hyperplasia 12. Hormone therapy (HT) (3) Continuous-combined regimen a. Indications (a) Estrogen and progestin every day (1) Relief of menopausal symptoms re- (b) Lower cumulative dose of proges- lated to estrogen deficiency—vasomo- tin than with cyclic regimens tor instability, vulvar/vaginal atrophy (c) May have unpredictable bleeding (2) Prevention of osteoporosis (d) After several months endome- b. Other potential benefits—reduction in risk trium atrophies and amenorrhea for colon cancer usually results c. Contraindications (e) No estrogen-free period during (1) Thromboembolic disorders or which vasomotor symptoms can thrombophlebitis occur (2) Known or suspected breast cancer (4) Continuous-cyclic regimen (3) Estrogen dependent cancer (a) Estrogen every day (4) Liver dysfunction or disease (b) Progestin added 10 to 14 days (5) Undiagnosed abnormal uterine each month bleeding (c) No estrogen-free period during (6) Known or suspected pregnancy which vasomotor symptoms can d. Potential risks occur (1) Endometrial hyperplasia/cancer (d) Withdrawal bleeding when pro- (2) Breast cancer gestin withdrawn each month (a) Relationship with HT (5) Cyclic regimen inconclusive (a) Estrogen days 1 to 25 (b) Possible small, but significant in- (b) Progestin added last 10 to 14 days crease of breast cancer with long- (c) Followed by 3 to 6 days of no term HT therapy (3) Gallbladder disease (d) Withdrawal bleeding when pro- (4) Thromboembolic disorders gestin withdrawn each month e. Assessment prior to initiation of HT (6) Continuous unopposed estrogen—for (1) Health history with attention to woman without uterus specific contraindications and h. Types of estrogen—17b estradiol, estradiol precautions acetate, conjugated estrogen, esterified es- (2) General physical examination, gyne- trogen, estropipate (estrone), estriol (plant cological examination with Pap test, based) breast examination, mammogram i. Types of progesterone/progestin— (3) Base decisions concerning HT use on medroxyprogesterone acetate, norethin- woman’s symptoms, treatment goals, drone, norethindrone acetate, norgestrel, benefit-risk analysis micronized progesterone (plant based) f. Routine follow-up after HT initiation j. Routes of administration (1) Reevaluate in 3 months—assess thera- (1) Oral peutic effectiveness and any problems (a) Estrogen, progestin or (2) Annual follow-up thereafter if no combination problems (b) First-pass metabolism determines (a) Evaluate continuing need for HT bioavailability and discontinue as appropriate (c) Increased HDL (b) Consider nonhormonal drugs for (d) Increased triglycerides osteoporosis prevention if long- (2) Transdermal patches term therapy needed Gynecology (Normal) 45

(a) Estrogen and progestin or estro- (2) Not effective in relief of vulvovaginal gen only symptoms; may have adverse effect (b) Can use with continuous-cyclic on lipid metabolism regimen or continuous-combined l. Testosterone may be added if extreme regimen vasomotor symptoms not relieved by es- (c) No significant impact on HDL or trogen alone; oral, transdermal, injections, triglycerides subcutaneous implants (d) May have less adverse effects on (1) May be especially useful after surgical gallbladder and coagulation fac- menopause tors than oral estrogen (2) May increase energy level, feeling of (3) Vaginal estrogen creams well being, libido (a) Treatment of vulvar and vaginal (3) Side-effects—acne, hirsutism, atrophy clitoromegaly (b) May use initially with oral estro- (4) Does not appear to have negative lipid gen to get more immediate relief effect but more studies needed (c) Will not provide relief from vaso- m. Bioidentical hormones motor symptoms (1) Hormones chemically identical to (d) Some systemic absorption hormones produced by women possible during their reproductive years— (e) Need cyclic progestin with intact 17b-estradiol, estrone, estradiol, pro- uterus gesterone, testosterone (4) Estrogen vaginal ring (Estring) (2) Bioidentical hormone therapy (BHT) (a) Little or no systemic absorption provides one or more of these hor- (b) Approved for treatment of vulvar/ mones as active ingredients vaginal atrophy (3) 17b-estradiol is available in several (c) Will not relieve vasomotor FDA-approved ET products in oral, symptoms transdermal, transcutaneous, and (d) 90 days duration vaginal preparations (e) Do not need cyclic progestin (4) One FDA-approved bioidentical pro- (5) Estrogen vaginal ring (Femring) gesterone product is available in oral (a) Systemic absorption form (b) Approved for treatment of vaso- (5) Custom compounded BHT uses com- motor symptoms and vulvar/ mercially available hormones with the vaginal atrophy type and amount prescribed by the (c) 90 days duration clinician (d) Requires added progestin if have (6) Custom compounded BHT products intact uterus are not FDA approved; there is no evi- (6) Topical sprays, gels, and emulsions— dence that they are safer than conven- 17b-estradiol tional HT; the same contraindications (a) Systemic absorption apply to their use (b) No significant impact on HDL or (7) No evidence that saliva testing is ef- triglycerides fective for customizing hormone dos- (c) May have less adverse effects on ing regimens gallbladder and coagulation fac- n. Side-effects of HT tors than oral estrogen (1) Breast tenderness—estrogen or pro- (d) Need cyclic progestin with intact gestin (usually subsides after first few uterus weeks) (e) Topical progesterone prepara- (2) Nausea—estrogen (relieved if taken at tions may not provide sufficient mealtime or bedtime) endometrial protection (3) Skin irritation with transdermal k. Progestin-only may be used if estrogen is patches contraindicated (4) Fluid retention and bloating—estro- (1) Effective in relieving vasomotor symp- gen or progestin toms; may have a positive impact on (5) Alterations in mood—estrogen or calcium balance progestin o. Management of side-effects may include: (1) Lowering dose 46 Chapter 3 Women’s Health

(2) Altering route of administration c. ACS—yearly if using conventional pap (3) Changing to different formulation smear or every 2 years if using liquid- p. Management of bleeding during HT based test (1) Continuous–cyclic regimen—usually d. ACOG—every 2 years from 21 to 29 years experience some uterine bleed- of age regardless of type of test used ing; starts last few days of progestin e. ACS and ACOG—for women age 30 and administration or during hormone- older who have had three consecutive free days; earlier bleeding, heavy or satisfactory normal pap tests, screening persistent bleeding may indicate en- may be done every 3 years unless history dometrial hyperplasia and warrants of in utero DES exposure, HIV infection, or endometrial evaluation immunosuppression (2) Continuous–combined regimen— f. ACOG—for women age 30 and older with erratic spotting and light bleeding of 1 combination of negative pap test and neg- to 5 days duration in first year; endo- ative HPV test, perform Pap tests no more metrial biopsy if bleeding heavier or than every 3 years longer than usual 3. Procedure 13. Nonhormonal management of vasomotor a. Instruct patient to avoid douching, inter- symptoms course, and use of vaginal creams for 48 a. Antidepressants (SSRI, SNRI), gabapen- hours prior to Pap test screening tin, clonidine—not FDA approved for this b. Midcycle sampling is ideal (avoid when purpose vaginal bleeding present) b. Avoiding caffeine, alcohol, cigarettes, spicy c. Speculum may be lubricated with water foods, and big meals prior to insertion c. Regular, moderate exercise—may also d. Entire squamocolumnar junction must help alleviate insomnia be sampled with spatula/broom to d. Wearing layers and natural fibers avoid false negative related to sampling e. Sleeping in a cool room technique f. Keeping a thermos of ice water available e. Endocervical sampling must be obtained g. Stress management and relaxation with broom/cytobrush techniques f. Rapid fixation with cytologic fixative is h. Vitamin E—anecdotal reports of relief, essential to avoid air-drying artifact un- placebo-controlled studies not supportive less specimen is transferred to aqueous i. Soy foods and isoflavine supplements solution 14. Nonhormonal management of vulvovaginal symptoms • Wet mounts (preparations) a. Water soluble lubricants 1. Purpose—to detect organisms responsible b. Regular sexual activity for symptoms of vulvar, vaginal, cervical, and c. Noncoital methods of sexual expression— uterine infections through microscopic evalu- massage, mutual masturbation if penetra- ation of vaginal discharge tion is painful 2. Procedure a. Obtain specimen from vaginal sidewalls Â Diagnostic Studies and b. Prepare initial slide with saline to detect Laboratory Tests clue cells, epithelial cells, RBC, WBC, trichomonads, yeast hyphae, and spores • Pap test c. Second specimen can be prepared with 1. Purpose—a screening technique KOH to facilitate visualization of yeast a. Increases detection and treatment of pre- buds and pseudohyphae cancerous and early cancerous lesions of d. Addition of KOH may also be used to de- the uterine cervix tect presence of amines (whiff test) b. Decreases morbidity and mortality from invasive cervical cancer • Colposcopy 2. Schedule 1. Purpose—to allow inspection of vagina and a. ACS—begin approximately 3 years after cervix using a binocular microscope; detects woman begins having vaginal intercourse lesions/abnormalities that may be biopsied for but not later than 21 years of age histologic examination b. ACOG—begin at 21 years of age 2. Procedure Diagnostic Studies and Laboratory Tests 47

a. Careful, thorough inspection with b. Confirm viability and location of colposcope gestation/products of conception b. Swab cervix/vagina; apply dilute acetic c. Determine endometrial thickness acid to cervix/vagina d. Evaluate size/location of uterine myomas c. Areas of abnormality identified e. Evaluate adnexal masses/fullness (1) Aceto white areas (1) Ectopic pregnancy (2) Vascular patterns (2) Ovarian cysts—serial evaluation (a) Punctuation f. Predict ovulation—infertility evaluation (b) Mosaicism g. Evaluate fetal growth (c) “Corkscrew” vessels h. Detect fetal anomalies/abnormalities d. Biopsy 2. Procedure (1) Identify squamous cell lesions indi- a. For transabdominal pelvic ultrasound, pa- cated by Pap test screen tient instructed to have full bladder (2) Apply silver nitrate/monsels if biopsy b. Transvaginal ultrasound does not require sites continue to bleed full bladder e. Endocervical curretage c. Transducer is passed over tissue to be ex- (1) Indicated for glandular abnormalities amined; breast, abdomen, pelvis indicated by Pap test (2) 360-degree sample of endocervical • Mammogram canal 1. Purpose—radiographic examination of the breast to determine presence of small cancer- • Pregnancy test ous, precancerous, and benign lesions 1. Purpose—to detect human chorionic gonado- 2. Equipment—mammograms should be per- tropin (hCG) in blood/urine; qualitative deter- formed at a site accredited by the American mines positive or negative test for pregnancy; College of Radiology Mammography Accredi- quantitative measures amount of hCG to tation Program to ensure low-dose, accurate ascertain gestational age; serial results deter- equipment, and trained professional staff mine viability/growth of conceptus 3. Procedure 2. Procedure for urine tests a. Instructions to avoid use of any under- a. Obtain first morning specimen if possible arm deodorant spray or powder prior to as it will be most concentrated procedure b. Assess client for use of drugs that may b. Typically two views taken of each breast cause false positive results, e.g., anticon- for screening mammogram vulsants, hypnotics, tranquilizers c. Results explained clearly and follow-up c. Assess urine for blood or protein if false planned accordingly positive suspected 4. Diagnostic mammography 3. Beta subunit radioimmunoassay (RIA)— a. Performed if suspicious lesion found on serum; quantitative; reliable at 7 days post- clinical or self-breast examination conception; no cross-reactivity with other b. Targets a specific area with multiple views hormones 5. Referral and/or biopsy recommended on any 4. Enzyme-linked immunosorbent assay clinically suspicious lesion regardless of mam- (ELISA)—immunometric test—urine or serum; mography results qualitative; quantitative—serum only; reliable at 7 to 10 days postconception; no cross- • Biopsy reactivity with other hormones 1. Endometrial 5. Agglutination inhibition test—urine; qualita- a. Purpose—to determine endometrial tive only; reliable at 14 to 21 days postcon- status, identify infection, inflammation, ception; cross-reactivity with FSH, LH, TSH hyperplasia, and malignancies in the possible with some tests endometrium (1) Evaluation of abnormal uterine • Ultrasound bleeding 1. Purpose—use of high-frequency sound waves (a) Perimenopausal to evaluate internal organs/ structure for diag- (b) Postmenopausal nostic purposes (2) Rule out/confirm endometritis a. Distinguish between solid and cystic ab- (3) Infertility evaluation dominal/breast or pelvic masses (a) “Date” the endometrium 48 Chapter 3 Women’s Health

(b) Confirm/rule out luteal phase 2. Neisseria gonorrhoeae (GC) defect a. Culture—cervix, urethra, rectum, pharynx; b. Procedure plated on Thayer-Martin/other medium (1) Bimanual examination—determine b. Nonculture tests—NAAT, EIA, DNA probe uterine position and size 3. Treponema pallidum (syphilis) (2) Local anesthesia may be injected/ a. Dark field microscopy examination and applied at site for tenaculum direct fluorescent antibody tests of lesion attachment exudate or tissue are definitive methods of (3) Attach tenaculum to stabilize cervix/ diagnosing early syphilis provide traction b. Serology—provides for presumptive (4) Paracervical block may be used diagnosis (5) Gently pass pipelle through cervix (1) Nontreponemal tests (6) Withdraw stilette/aspirate with sy- (a) Venereal Disease Research Labo- ringe while rotating pipelle ratories (VDRL) (7) Transfer contents of pipelle/syringe (b) Rapid plasma reagin (RPR) into fixative (c) Become positive 1 to 2 weeks past (8) Remove tenaculum—control bleeding chancre (a) Silver nitrate (d) Reported as nonreactive or (b) Monsel’s solution reactive 2. Cervical—see colposcopy (e) Reactive test also reported quanti- 3. Breast tatively as titer a. Purpose—fine needle biopsy to determine (f) Nonspecific whether breast mass found on examina- (g) False positives associated with tion or through imaging contains benign mononucleosis, collagen vascular or malignant cells disease, and some other medical b. Procedure conditions; usually see low titer (1) Area identified and local anesthetic 1:8 injected superficially (h) Reactive nontreponemal tests (2) 21-gauge needle attached to syringe must be confirmed with a inserted directly into area treponemal test (3) Negative pressure applied through (i) Titers are also used for follow up aspiration with syringe after treatment (4) Contents placed in specimen (j) Nontreponemal tests usually be- container/slide with fixative come nonreactive with time after 4. Vulvar treatment a. Purpose—sample areas of vulva that ap- (2) Treponemal tests pear abnormal for diagnostic purposes (a) Fluorescent treponemal antibody b. Procedure absorption test (FTA-ABS) (1) Area identified and local anesthetic (b) Treponema pallidum immobiliza- injected tion test (TPI) (2) Punch biopsy instrument used in ro- (c) Reported as positive or negative; tating motion to remove sample not quantitative (3) Specimen placed in histologic (d) Specific solution (e) Treponemal tests usually re- (4) Bleeding controlled with silver main positive indefinitely after nitrate/Monsel’s solution treatment 4. Genital herpes simplex • Screening tests for sexually transmitted diseases a. Tissue culture of lesion (STD) (1) Gold standard test 1. Chlamydia trachomatis (2) Sensitivity varies with stage of infec- a. Tissue culture—endocervix, urethra, rec- tion—highest if sample of vesicular tum, pharynx lesion b. Nucleic acid amplification test (NAAT)— b. Other tests available—DNA probe testing, test recommended by CDC; includes op- direct fluorescent antibody/enzyme assay, tion of testing with urine sample polymerase chain reaction (PCR) c. Other nonculture tests—direct fluorescent c. Type-specific serologic tests—serum; antibody (DFA), enzyme immunoassay detect presence of HSV-1 and HSV-2 (EIA), DNA probe Diagnostic Studies and Laboratory Tests 49

antibodies; may take 4 to 12 weeks for se- 2. Estradiol—pg/mL roconversion; useful if history suggestive a. Follicular phase—20 to 150 of HSV but no current lesions, negative b. Midcycle—150 to 750 culture of lesions but suspect HSV infec- c. Luteal phase—30 to 450 tion, partner with known HSV infection, or d. Postmenopause—20 or less patient with HIV infection 3. Follicle stimulating hormone—mIU/mL d. Cytologic tests—Pap test and Tzanck prep- a. Follicular phase—5 to 25 aration are insensitive and nonspecific; b. Midcycle—20 to 30 should not be relied on for diagnosis b. Luteal phase—5 to 25 5. Human papillomavirus (HPV) c. Postmenopause—40 to 250 a. Condyloma acuminata (genital warts) 4. Luteinizing hormone—mIU/mL (1) Generally diagnosed by inspection a. Follicular phase—5 to 25 (2) Punch biopsy—rarely needed unless b. Midcycle—75 to 150 uncertain of lesion c. Luteal phase—5 to 40 b. Cervical/flat condyloma/HPV d. Postmenopause—30 to 200 (1) Inspection by colposcopy after acetic 5. Progesterone—ng/mL acid stain application a. Follicular phase—less than 2 (2) Cervical cytology (Pap test) b. Luteal phase—2 to 20 (3) Viral DNA testing c. Postmenopause—less than 0.2 6. Chancroid—culture/DNA probe 7. Trichomoniasis • Laparoscopy a. Microscopic evaluation of vaginal secre- 1. Purpose—to provide direct visualization of tions with saline wet mount internal reproductive organs for diagnosis and (1) Motile, flagellated protozoa treatment of certain conditions (2) Greater than 10 WBC/high power field a. Provides for inspection of internal repro- b. Vaginal pH greater than 4.5 ductive organs 8. Hepatitis B (HBV) b. Diagnostic for endometriosis a. Serologic testing c. Assists in diagnosis of b. Hepatitis B surface antigen (HBsAg)—seen (1) Pelvic pain with active infection; carrier state (2) Infertility c. Hepatitis B surface antibody (HBsAb)— (3) Ectopic pregnancy seen with convalescence, indicates immu- (4) Ovarian cysts/neoplasia nity to HBV (5) Uterine fibroids d. Hepatitis B core antibody (HBcAb)—indi- (6) Pelvic adhesions cates past infection; chronic hepatitis d. Therapeutic uses e. Hepatitis B e-antigen (HBeAg)—seen with (1) Tubal ligation acute infection; indicates infectivity (2) Appendectomy f. Hepatitis B e-antibody (HBeAb)—seen (3) Infertility procedures—harvesting ova with convalescence; indicates decreased for IVF or GIFT procedure infectivity (4) Lyse adhesions 9. Human immunodeficiency virus (HIV) (5) Laser/fulguration of endometrial a. Sensitive screening tests—enzyme immu- implants noassay (EIA) or rapid test; 99% sensitivity 2. Procedure at longer than 12 weeks postexposure a. General anesthesia administered b. Reactive screening tests must be con- b. Incision into peritoneal cavity

firmed by supplemental tests that are c. CO2 instilled—approximately 3 liters highly specific—Western blot or immu- (1) Distends abdominal cavity nofluorescence assay (IFA); HIV antibody (2) Allows visibility of organs detectable in 95% of individuals within 6 d. Second small incision made; laparoscope months of infection inserted—facilitates inspection e. Additional incision made to facilitate in- • Serum hormonal levels strumentation if procedure performed 1. Purpose—to evaluate and monitor treatment f. Patient may experience abdominal/ of infertility; to assist in differential diagnosis referred shoulder pain following proce-

of gonadal dysfunction; to assist in diagnosis dure related to CO2 instillation of certain neoplasms 50 Chapter 3 Women’s Health

• Bone density testing/Bone densitometry of endometrium; stabilizes endometrium; 1. Purpose—diagnosis and monitoring treatment potentiates progestin

of osteoporosis (1) Ethinyl estradiol (E2)—most prevalent 2. Procedure for DEXA scan—most-used synthetic estrogen in COC technique (2) Mestranol—weaker estrogen; utilized a. Patient lies supine while imager passes in older COC formulations over body b. Progestin—inhibits ovulation through b. Process takes about 10 to 15 minutes suppression of LH; produces atrophic en- c. Computer calculates density of patient’s dometrium; thickens cervical mucus; de- bones creases ovum transport through fallopian 3. Image/regions scanned tube; may inhibit capacitation of sperm a. Hip (1) Norethindrone b. Spine (2) Norethindrone acetate c. Wrist/forearm (3) Norgestrel d. Heel (4) Levonorgestrel 4. Dual energy x-ray absorptiometry (DEXA) (5) Ethynodiol diacetate a. Multiple sites—femoral neck and lumbar (6) Norgestimate spine most common; also finger, forearm, (7) Desogestrel heel; hip BMD is best predictor of hip frac- (8) Gestodene (not available in US) tures and predicts fractures at other sites (9) Drosperinone b. Most-utilized method 3. Effectiveness/First year failure rate c. Low radiation a. Perfect use—0.1% 5. Quantitative computerized tomography b. Typical use—5% a. Spine and forearm 4. Advantages b. Greater radiation exposure a. Ease of use c. Expensive b. Reversible 6. Single x-ray absorptiometry (SXA)—heel c. Effective 7. Quantitative ultrasound—tibia or heel d. May reduce incidence of/afford protection 8. Assessment (T-score)—bone density com- against pared to a young normal adult (1) Acne a. Normal—BMD within 1 standard devia- (2) Dysmenorrhea tion (SD) of young normal adult; T-score (3) Pelvic inflammatory disease above –1 (4) Ectopic pregnancy b. Osteopenia—BMD between 1 and 2.5 SD (5) Endometriosis below that of young normal adult; T-score (6) Anemia between –1 and –2.5 (7) Osteoporosis c. Osteoporosis—BMD 2.5 SD or more below (8) Benign breast disease that of young normal adult; T-score at or (9) Functional ovarian cysts below –2.5 (10) Ovarian cancer; endometrial cancer (11) Atherogenesis Â Fertility Control (12) Rheumatoid arthritis (13) Migraine headaches • Combination oral contraceptives (COC) (14) Premenstrual syndrome 1. Description—pill taken daily for contraception (15) May be used as emergency or for specific noncontraceptive benefits; com- contraception bination of estrogen and progestin 5. Disadvantages/side-effects a. Monophasic pills—deliver constant a. Does not prevent transmission of amount of estrogen/progestin throughout STD/HIV cycle b. Requires user compliance/daily dosing b. Multiphasic pills—vary amount of estro- schedule gen and/or progestin delivered through- c. Side-effects may include: out cycle (1) Estrogenic effects c. Patterns of use—monthly cycling (21/7), (a) Nausea shortened pill-free interval, extended cycle (b) Increased breast size 2. Mechanism of action (c) Cyclic weight gain a. Estrogen—inhibits ovulation through sup- (d) Leukorrhea pression of FSH, alters cellular structure (e) Cervical eversion/ectopy Fertility Control 51

(f) Hypertension (5) History of DVT or PE and one or more (g) Increased cholesterol concentra- risk factors for recurrence tion in gallbladder bile (6) Major surgery with prolonged (h) Growth of leiomyomata immobilization (i) Telangiectasia (7) Known thrombogenic mutations (j) Chloasma (8) History of or current ischemic heart (k) Hepatocellular adenomas/cancer disease, stroke, complicated valvular (rare) heart disease (l) Cerebrovascular accidents (9) Migraine headaches with aura at any (m) Thromboembolic complications age; migraine headache at 35 years of including pulmonary emboli age or older with/without aura (n) Stimulation of breast neoplasia (10) Breast cancer within past 5 years (2) Progestogenic side-effects (alone or in (11) Diabetes with nephropathy, retinopa- combination with estrogen) thy, neuropathy, other vascular dis- (a) Breast tenderness ease; or longer than 20 years duration (b) Headaches (12) Active viral hepatitis, severe cirrhosis, (c) Hypertension hepatocellular adenoma, malignant (d) Decreased libido hepatoma (3) Androgenic effects (13) Systemic lupus erythematosus (SLE) (a) Increased appetite/weight gain with positive or unknown antiphos- (b) Depression, fatigue pholipid antibodies (c) Acne, oily skin (14) Peripartum cardiomyopathy—normal (d) Increased breast tenderness/size or mildly impaired cardiac function (e) Increased LDL cholesterol and less than 6 months postpartum; (f) Decreased HDL cholesterol moderately or severely impaired car- (g) Decreased carbohydrate diac function tolerance/increased insulin (15) Solid organ transplantation with resistance complications (h) Pruritus c. Category 3 for COC use—use of the 6. Contraindications (Centers for Disease Control method not generally recommended for and Prevention [CDC] recommendations) the following conditions unless other a. Individual characteristics or known pre- more appropriate methods are not avail- existing medical/pathologic condition able or acceptable: affecting eligibility for use of a contracep- (1) Breastfeeding and less than 1 month tive method classified under one of four postpartum categories (CDC, 2010) (2) Less than 21 days postpartum if not (1) Category 1—condition for which there breastfeeding is no restriction on use of the method (3) Smoker 35 year of age or older, less (2) Category 2—condition where advan- than 15 cigarettes/day tages of using method generally out- (4) Hypertension—adequately controlled weigh theoretical or proven risks or 140–159/90–99 (3) Category 3—condition where theoret- (5) Known hyperlipidemia—consider ical or proven risks usually outweigh type, severity, and other cardiovascu- advantages of using method lar risk factors (4) Category 4—condition that represents (6) Migraine headache without aura and an unacceptable health risk if method less than 35 years of age that starts or is used worsens with COC use b. Category 4 for COC use—do not use (7) History of breast cancer with no evi- method if following conditions exist: dence of disease for 5 years (1) Smoker 35 year of age or older, 15 or (8) Symptomatic gallbladder disease; his- more cigarettes/day tory of cholestasis related to past COC (2) Multiple risk factors for arterial car- use diovascular disease (9) Mild cirrhosis (3) Hypertension ($160/$100) or hyper- (10) History of bariatric surgery with mal- tension with vascular disease absorptive procedure (4) Acute deep vein thrombosis (DVT) or (11) History of DVT or PE with no risk fac- pulmonary embolism (PE) tors for recurrence 52 Chapter 3 Women’s Health

(12) Peripartum cardiomyopathy with (a) Occurs in about 5% of women af- normal or mildly impaired cardiac ter several years of COC use function and 6 or more months (b) Rule out pregnancy postpartum (c) No intervention required if (13) Moderate or severe inflammatory woman is okay with no menses bowel disease with associated risks for (d) Change to 30–35 mcg estrogen if DVT or PE on 20 mcg COC 7. Management (e) Add supplemental estrogen to a. Health assessment prior to initiation of regimen for first 3 weeks of one method cycle (1) Elicit information from thorough 8. Instructions for use history concerning any contraindica- a. General instructions tions/risk to use of COCs (1) Quick start—reasonably certain not (2) Pelvic examination/Pap test not re- pregnant, take first pill on day of office quired prior to initiating COC unless visit; backup method for 7 days other indications (2) First day start—take first pill on first (3) Blood pressure day of menses; no backup method (4) Clinical breast examination if 20 years needed of age or older recommended (3) Sunday start—take first pill on first (5) Mammogram if age 40 or older Sunday after menses starts; use b. Health assessment at follow-up visits backup method for 7 days (1) Patients may be assessed yearly if no (4) Pill taken at approximately same time risk factors each day (2) Patients with risk factors may be seen (5) If nausea occurs, pill can be taken at 3 to 6 month intervals with meals or at bedtime c. Special considerations (6) Backup method (condoms) used if (1) Drug interactions—drugs that may efficacy/absorbency compromised by decrease the effectiveness of COC severe vomiting/diarrhea include: (7) Condom use for prevention of (a) Rifampin STD/HIV (b) Lamotrigine b. Missed pills (c) Phenobarbital (1) If one or two pills missed, take one (d) Phenytoin active pill as soon as remembered (e) Topirimate and next pill taken at normal time, (f) Carbamazepine no backup method needed; consider (g) Primidone emergency contraception (EC) if pills (h) Saint John’s Wort missed in first week and sexual inter- (i) Some antiretroviral drugs course was unprotected (2) Drug interactions—COC may potenti- (2) If three or more pills missed in weeks ate effect of some drugs 1 or 2, take two pills on day remem- (a) Benzodiazepines bered and then resume one pill each (b) Anti-inflammatory corticosteroids day; use backup method for 7 days; (c) Bronchodilators consider emergency contraception (3) Management of breakthrough (EC) if pills missed in first week and bleeding/spotting sexual intercourse was unprotected (a) Common side-effect of first 3 (3) If three or more pills missed in week 3 months of use (of traditional 4-week pack); finish ac- (b) Reinforce to take pills daily at the tive pills of current pack; do not take same time placebo pills; start new pack next day (c) Change to 30–35 mcg estrogen if c. Warning signs (ACHES) on 20 mcg COC (1) Abdominal pain (severe) (d) Change to COC with different (2) Chest pain (sharp, severe, shortness of progestin breath) (e) If problem persists consider an- (3) Headache (severe, dizziness, other cause for bleeding, e.g., in- unilateral) fection, polyps (4) Eye problems (scotoma, blurred vi- (4) Management of absence of with- sion, blind spots) drawal bleeding (5) Severe leg pain (calf or thigh) Fertility Control 53

• Progestin-only pills (POP) (3) History of bariatric surgery with mal- 1. Description—pill taken daily for purposes of absorptive procedure contraception; comprised of synthetic proges- (4) Ischemic heart disease or stroke oc- tins in lower doses than those used in combi- curring while on POP nation oral contraceptive pills (5) Migraine with aura at any age that 2. Mechanism of action starts or worsens with POP use a. Inhibits ovulation through suppression of (6) SLE and positive or unknown an- FSH and LH tiphospholipid antibodies b. Produces atrophic endometrium (7) Taking ritonivar-boosted protease c. Thickens cervical mucus inhibitors as part of HIV/AIDS treat- d. Slows ovum transport through fallopian ment; some anticonvulsants; rifampin tube or rifabutin e. May inhibit sperm capacitation 7. Management 3. Effectiveness/First year failure rate a. Health assessment prior to initiation of a. Perfect use—0.5% method—refer to COC section b. Typical use—5% b. Health assessment at follow-up visits— 4. Advantages refer to COC section a. Ease of use c. Special considerations—ectopic preg- b. Reversible nancy more likely if pregnancy occurs c. Effective 8. Instructions for using the method d. Contains no estrogen for women in whom a. General instruction it is contraindicated or who cannot toler- (1) Pills started on cycle day 1 (first day of ate estrogenic side-effects menses) e. Can be used during lactation (2) Pill taken at same time each day every 5. Disadvantages and side-effects day; no placebo/off week a. Effectiveness may be compromised (3) If more than 3 hours late taking pill, by drug interactions due to low-dose backup method should be used for 48 formulation hours (1) Rifampin b. Warning signs (2) Phenobarbital (1) Severe low abdominal pain (3) Phenytoin (2) No bleeding after series of regular (4) Primidone cycles (5) Carbamazepine (3) Severe headache (6) Griseofulvin b. Decreased availability/increased expense • Transdermal contraceptive system compared to COC 1. Description—patch applied to skin; delivers c. Strict daily dosing schedule continuous daily systemic dose of progestin d. Possible side-effects include: (norelgestromin) and estrogen (ethinyl estra- (1) Increased incidence of functional fol- diol), new patch applied each week for 3 weeks licular cysts followed by 1 week without patch to induce (2) Menstrual cycle irregularities withdrawal bleeding (3) Mastalgia 2. Mechanism of action—same as COC (4) Depression 3. Effectiveness/First year failure rate e. No protection against STD/HIV a. Perfect use—0.99% 6. Contraindications (CDC recommendations) b. Typical use—1.24% a. Category 4 for POP use—do not use 4. Advantages method if breast cancer within past 5 a. Ease of use—no daily dosing regimen years b. Reversible b. Category 3 for POP use—use of the c. Effective method not generally recommended for d. Good menstrual cycle control the following conditions unless other 5. Disadvantages and side-effects more appropriate methods are not avail- a. Does not prevent transmission of able or acceptable: STD/HIV (1) History of breast cancer with no evi- b. Skin irritation at application site dence of disease for 5 years c. Other side-effects similar to those of COC (2) Severe cirrhosis, benign hepatocellu- 6. Contraindications (CDC recommendations)— lar adenoma, malignant hepatoma same as with COC except history of bariatric surgery not relevant 54 Chapter 3 Women’s Health

7. Management 7. Management a. Health assessment prior to initiation— a. Health assessment prior to initiation— same as with COC same as with COC b. Health assessment at follow-up visits— b. Health assessment at follow-up visits same as with COC (1) Requires injection every 28 to 30 days c. Special considerations (2) Assess for side-effects/problems (1) May be less effective in women who c. Special considerations weigh 90 kg (198 pounds) or more (1) If more than 33 days between injec- (2) Probably same drug interactions as tions, increased risk for pregnancy with COC (2) Probably same drug interactions as 8. Instructions for using the method with COC a. Quick start—reasonably certain not preg- 8. Instructions for using the method nant, apply patch on day of office visit or a. Administer injection intramuscularly in when convenient; backup method for 7 deltoid, anterior thigh, gluteal muscle days b. Administer first injection within 5 days of b. First day start—apply patch on first day of start of menstrual period menses; no backup method needed c. Administer new injection every 28 to 30 c. Sunday start—apply patch on first Sunday days (33 days at most) after menses starts; use backup method d. May have bleeding 2 to 3 weeks after first for 7 days injection d. Patch applied to buttocks, abdomen, up- e. Then regular bleeding pattern occurring per torso front or back (excluding breasts), 22 to 25 days after each injection upper outer arm f. Use backup method of contraception if e. New patch applied on same day each week late for injection for total of 3 weeks g. Consider use of condoms for STD/HIV f. Patch not worn on week 4; withdrawal prevention bleeding will occur h. Healthcare provider contacted if warning g. Use of condoms considered for STD/HIV signs occur—same as COC warning signs prevention h. New patch applied if current patch par- • Contraceptive vaginal ring (NuvaRing) tially or completely pulls away from skin 1. Description—soft, malleable, clear plastic i. Healthcare provider contacted if warning ring; delivers continuous, systemic dose of signs occur—same as COC warning signs estrogen (ethinyl estradiol) and progestin (etonogestrel); worn in vagina for 3 weeks fol- • Combination injectable contraceptives (Lunelle)— lowed by 1 week without ring to induce with- no longer available in US; available in other drawal bleeding countries 2. Mechanism of action—same as COC 1. Description—intramuscular injection admin- 3. Effectiveness/First year failure rate istered every 28 to 30 days for contraception; a. Perfect use—0.3% combination of estrogen (estradiol cypionate) b. Typical use—2% and progestin (medroxy-progesterone acetate) 4. Advantages 2. Mechanism of action—same as COC a. Ease of use—no daily dosing regimen 3. Effectiveness/First year failure rate b. Reversible a. Perfect use—0.3% c. Effective b. Typical use—0.3% d. Good menstrual cycle control 4. Advantages 5. Disadvantages and side-effects a. Ease of use—no daily dosing regimen a. Does not prevent transmission of b. Reversible STD/HIV c. Effective b. Side-effects similar to those of COC d. Good menstrual cycle control c. Vaginal discharge/vaginal irritation 5. Disadvantages and side-effects 6. Contraindications (CDC recommendations)— a. Does not prevent transmission of same as with COC except history of bariatric STD/HIV surgery not relevant b. Side-effects similar to those of COC 7. Management 6. Contraindications (WHO recommendations)— a. Health assessment prior to initiation— same as with COC; not included in CDC same as with COC recommendation Fertility Control 55

b. Health assessment at follow-up visits— d. Does not require compliance with daily/ same as with COC event regimen c. Special considerations—probably same e. Does not have drug interaction profile drug interactions as with COC f. Results in absence of menstrual bleeding 8. Instructions for using the method in up to 50% of women by end of first year a. Quick start—reasonably certain not preg- of use (four injections); by end of second nant, insert ring on day of office visit or year, 70% are amenorrheic when convenient; backup method for 7 g. Contains no estrogen for women in whom days it is contraindicated or who cannot toler- b. First day start—insert ring on first day of ate estrogenic side-effects menses; no backup method needed h. Can be used during lactation c. Days 2 to 5 of menstrual cycle—insert ring i. May decrease the following and use backup method for 7 days (1) Intravascular sickling in patients with d. Hands washed before inserting sickle cell disease e. Ring folded and gently inserted into (2) Incidence of seizures in affected vagina individuals f. Exact position of ring in vagina is not 5. Disadvantages/side-effects important a. Menstrual cycle irregularities g. Ring left in vagina for 3 weeks then b. Mastalgia removed c. Depression h. New ring inserted in 7 days d. No protection against STD/HIV i. If ring is expelled or removed for 3 hours e. Not immediately reversible—requires 3 or more, backup method used for next 7 months to be eliminated days after ring is reinserted in vagina f. Requires routine 3-month injection j. If ring is left in vagina for more than 3 schedule weeks but less than 4 weeks, it should be g. Weight gain removed; new ring inserted after 1 week (1) Average 5.4 pounds first year ring-free period (2) 13.8 pounds after 4 years k. If ring is left in vagina more than 4 weeks, h. 6 to 12 month delayed return to fertility in it may not protect from pregnancy; some women backup method used until new ring in va- i. Decreased bone density in long-term gina for 7 days (greater than 5 years) user—returned to l. Use of condoms considered for STD/HIV normal following discontinuance prevention j. May decrease HDL cholesterol m. Healthcare provider contacted if warning 6. Contraindications (CDC recommendations) signs occur—same as COC warning signs a. Category 4 for DMPA use—do not use method if breast cancer within past 5 • Progestin-only injectable contraception (Depo- years Provera DMPA) b. Category 3 for DMPA use—use of the 1. Description—intramuscular or subcutaneous, method not generally recommended for injectable progestin administered in 3-month the following conditions unless other intervals for contraception more appropriate methods are not avail- 2. Mechanism of action able or acceptable: a. Inhibits ovulation through suppression of (1) Multiple risk factors for arterial car- FSH and LH diovascular disease b. Produces atrophic endometrium (2) Hypertension ($160/100) or with vas- c. Thickens cervical mucus cular disease d. Slows ovum transport through fallopian (3) Current/history of ischemic heart dis- tube ease or stroke e. May inhibit sperm capacitation (4) Migraine with aura at any age that 3. Effectiveness/First year failure rate starts or worsens with DMPA use a. Perfect use—0.3% (5) History of breast cancer with no evi- b. Typical use—0.3% dence of disease for 5 years 4. Advantages (6) Unexplained vaginal bleeding before a. Ease of use evaluation b. Effective (7) Diabetes with nephropathy, retinopa- c. Long-term contraceptive option thy, neuropathy, other vascular disease; or longer than 20 years duration 56 Chapter 3 Women’s Health

(8) Severe cirrhosis, benign hepatocellu- SC formulation—anterior thigh or ab- lar adenoma, malignant hepatoma dominal wall (9) SLE with positive or unknown an- (2) Do not massage injection site (alters tiphospholipid antibodies absorption/efficacy) (10) SLE with severe thrombocytopenia— (3) Observe patient for 20 minutes follow- initiation category 3, continuation ing first injection to rule out allergic category 2 reaction (11) Rheumatoid arthritis or long-term f. Warning signs corticosteroid therapy with history (1) Frequent intense headache of or risk factors for nontraumatic (2) Heavy, irregular bleeding fractures (3) Depression 7. Management (4) Abdominal pain (severe) a. Health assessment prior to initiation of (5) Signs of infection at injection site method (prolonged redness, bleeding, pain, (1) Refer to COC section discharge) (2) Include relevant health history (3) Baseline weight assessment • Progestin-only implants b. Health assessment at follow-up visits 1. Etonogestrel implant (Implanon) (1) Return every 3 months for injection a. Description—long-term (3 years) contra- (2) Determine bleeding pattern— ceptive; single rod-shaped implant placed hematocrit/hemoglobin if excessive subdermally inner side of upper arm; (3) Assess for side-effects/problems provides low dose sustained release of the (4) Weight progestin etonogestrel c. Special considerations b. Mechanism of action (1) May have added benefits for women (1) Suppresses LH—ovulation inhibited with in almost all users (a) Seizure disorder—some data in- (2) Produces atrophic endometrium dicate decrease in frequency of (3) Thickens cervical mucus grand mal seizures; seizure medi- c. Effectiveness/First year failure rate cation has no impact on DMPA (1) Perfect use—0.01% efficacy (2) Typical use—0.01% (b) Sickle cell disease—some data in- (3) Unknown if overweight/obesity may dicate association with reduction reduce efficacy in frequency of sickle cell crises d. Advantages (2) No adverse effect on milk volume after (1) Ease of use established and may enhance milk (2) Effective production in lactating woman (3) Reversible—most users ovulate within 8. Instructions for using the method 6 weeks after removal a. Explain importance of adherence to (4) Contains no estrogen for women with 3-month injection schedule—contracep- contraindications to estrogen or who tive efficacy maintained for 14 weeks after cannot tolerate estrogenic side-effects injection (5) Can be used during lactation b. Administer first injection within first 5 (6) Affords long-term contraception days of menstrual period; no backup (3 years) method needed e. Disadvantages and side-effects c. If irregular menses, rule out pregnancy— (1) Requires clinician insertion and re- menstrual/coital history and pregnancy moval, removal requires minor surgi- test; use backup method for 7 days after cal procedure injection (2) Specific information on drug interac- d. Counsel patients regarding possibility of tions is not available, very low dose irregular bleeding; use of backup contra- progestin, potential for reduced effi- ception if more than 3 months between cacy with same drugs as listed for POP injections; use of condoms for STD/HIV (3) Pain, bruising, infection (potential) at prevention insertion site e. Procedure for injection (4) Irregular, prolonged, more frequent (1) IM formulation—deep intramuscular uterine bleeding especially in first few injection in deltoid or gluteal muscle; months; may have amenorrhea Fertility Control 57

(5) No protection against STD/HIV (6) Discuss use of condoms for STD (6) Implant may be visible prevention (7) Possible side-effects include (7) Warning signs to report (a) Increased incidence of functional (a) Abdominal pain (severe) ovarian cysts (b) Arm pain or signs of infection (b) Headache (c) Heavy vaginal bleeding (c) Emotional lability (d) Missed menses after period of (d) Breast tenderness regularity (e) Loss of libido (e) Onset of severe headaches (f) Vaginal secretion changes—dry- 2. Levonorgestrel implant (Norplant)—not cur- ness, leukorrhea rently available in US, although some women (g) Acne may still have these implants; long-term (5 f. Contraindications (CDC years) contraceptive system of six rod-shaped recommendations) implants placed subdermally in inner upper (1) Category 4 for etonogestrel implant arm; provides low dose sustained release of use—do not use method if breast can- progestin levonorgestrel cer within past 5 years (2) Category 3 for use etonogestrel im- • Emergency contraception plant—use of the method not gener- 1. Definition—method used to prevent con- ally recommended for the following ception after unprotected coitus; involves conditions unless other more appro- use of either hormone-containing pills— priate methods are not available or levonogestrel alone (Plan B or generic), or acceptable: combination of ethinyl estradiol and nor- (a) Ischemic heart disease or stroke gestrel or levonogestrel (COC), or copper- occurring while using method containing intrauterine contraception (IUC) (b) Migraine headaches with aura at 2. Mechanism of action any age if starts or worsens after a. Emergency contraception pill (ECP) implant insertion (1) Inhibits or delays ovulation (c) Unexplained vaginal bleeding be- (2) May alter sperm/ova transport fore evaluation (3) Will not disrupt an established preg- (d) History of breast cancer with no nancy—minimal endometrial effect evidence of disease for 5 years b. Copper-containing IUC (e) Severe cirrhosis, benign hepa- (1) Prevents fertilization (regular use) tocellular adenoma, malignant (2) Interferes with implantation hepatoma 3. Effectiveness (f) SLE with positive or unknown an- a. ECP tiphospholipid antibodies (1) Depends on preexisting fertility g. Management (2) Reduces risk of pregnancy by at least (1) Health assessment prior to initiation 75% of method—same as COC b. Copper-containing IUC—reduces risk of (2) Health assessment at follow-up visits pregnancy by more than 99% (a) Return 1 month after insertion to 4. Advantages assess site a. Provides means of emergency contracep- (b) Routine annual visits tion in event of any of the following: h. Instructions for using the method (1) Unplanned intercourse (1) Discuss possible bleeding changes (2) Method failure—condom breaks/ prior to insertion leaks; IUC expelled; cap/diaphragm (2) Inform patient must be replaced every dislodged/improperly placed 3 years for effective contraception (3) Missed COC pills at beginning of pack (3) Insert within days 1 to 5 of menses; no (4) Late for contraceptive injection backup method needed (5) ECP may be provided with instruc- (4) If irregular menses, rule out preg- tions for use for women using any nancy with menstrual and coital his- contraceptive method tory and pregnancy test b. Can provide continuous contraception (5) If inserted other than days 1 to 5 of (IUC) menses, use backup method for 7 5. Disadvantages and side-effects days a. ECP 58 Chapter 3 Women’s Health

(1) Nausea/vomiting—less common with (c) Available as prescription for fe- levonorgestrel-only (Plan B or generic) males younger than 17 years of (2) Change in next menses age b. Copper-containing IUC (6) COC (1) Irregular, heavy bleeding (a) Two doses of 100 to 120 mcg ethi- (2) Uterine cramping/abdominal pain nyl estradiol + 0.50 to 0.60 mg (3) Refer to section on IUC levonorgestrel or norgestrel 12 6. Precautions and risks hours apart a. Contraindications (CDC recommen- (b) May be 5-, 4-, or 2-pill regimen dations) for ECP—no category 3 or 4 depending on brand used contraindications (c) Caution regarding correct pills to b. Contraindications (CDC recommenda- use in triphasic pack tions) for copper-containing IUC—see b. Copper-containing IUC IUC section (1) Can be inserted up to 5 days after un- 7. Management protected sex a. Health assessment prior to initiation of (2) No evidence that progestin-containing method IUC offers effective emergency (1) Health history—menstrual, first epi- contraception sode of unprotected sex in cycle to determine if need pregnancy test, • Intrauterine contraception (IUC) last episode of unprotected sex to as- 1. Description—device placed in uterus for pur- sure within time frame for emergency pose of long-acting contraception contraception a. Copper T 380A (2) Urine pregnancy test if episode of un- (1) “T” shaped plastic device with copper protected sex more than 1 week ago wrapped around both vertical stem (3) If using IUC—see IUC section for re- and horizontal arms quired history and examination (2) Effective for 10 years (4) Discuss/provide ongoing b. Levonorgestrel Intrauterine System (LNG contraception IUS) b. Health assessment at follow-up visits (1) “T” shaped plastic frame with steroid (1) Pregnancy test if no menses within 3 reservoir in vertical stem that contains weeks levonorgestrel (2) Routine follow-up for ongoing (2) 20 mcg of levonorgestrel released daily contraception into uterine cavity 8. Instructions for using the method (3) Effective for 5 years a. ECP 2. Mechanism of action (1) Begin first dose as soon as possible a. Copper T 380A after unprotected sex and within 120 (1) Copper may inhibit sperm hours for maximum effectiveness capacitation (2) If vomiting within 2 hours, provide (2) Alters tubal/uterine transport of ovum with anti-emetic to take 1 hour before (3) Enzymatic influence on endometrium a repeated dose of ECP b. LNG IUS—progestin influence (3) Inform client that ECP will not pro- (1) Thickens cervical mucus vide any ongoing protection from (2) Produces atrophic endometrium pregnancy (3) Slows ovum transport through tube (4) Provide with contraception of (4) Inhibits sperm motility and function choice—resume current method or 3. Effectiveness/First year failure rate begin new method immediately; wait a. Perfect use until next day to start or restart oral (1) Copper T—0.6% contraceptives to prevent nausea/ (2) LNG IUS—0.71% vomiting b. Typical use (5) Levonorgestrel-only (Plan B or (1) Copper T—0.8% generic) (2) LNG IUS—0.71% (a) One dose of 1.5 mg levonor- 4. Advantages gestrel—one pill (Plan B) or two a. Ease of use pills (generic) b. Not coitally dependent (b) Available OTC if 17 years of age or c. Effective older d. Reversible Fertility Control 59

e. Cost-effective (if used longer than 1 year) (5) High likelihood of exposure to chla- f. LNG IUS can decrease blood loss during mydia or gonorrhea—initiation but menses not continuation g. Effective choice for women who cannot (6) AIDS—unless clinically well on anti- use estrogen-containing methods retroviral therapy—initiation but not h. Can be used during lactation continuation 5. Disadvantages and side-effects (7) Severe cirrhosis, benign hepatocel- a. Altered menstrual bleeding patterns lular adenoma, or malignant hepa- (1) Increased amount and length of men- toma—LNG IUS only strual bleeding—Copper T; first few (8) SLE with positive or unknown an- months of LNG IUS tiphospholipid antibodies—LNG IUS (2) Increased dysmenorrhea—Copper T only (3) Absence of bleeding—LNG IUS (9) SLE with severe thrombocytopenia— b. Risk of PID—increased risk first 20 days initiation of Copper T IUC only following insertion (10) Solid organ transplantation with c. Risk of spontaneous expulsion complications—initiation but not (1) May go undetected by the woman continuation (2) More likely at time of menses (11) Pelvic tuberculosis—continuation 6. Contraindications (CDC recommendations) 7. Management a. Category 4 for IUC use—do not use a. Health assessment prior to initiation of method if following conditions exist: method (1) Known/suspected pregnancy (1) History to include (2) Postpartum or postabortion sepsis (a) STD/PID, vaginitis symptoms (3) Unexplained vaginal bleeding prior to (b) STD risk factors insertion and before evaluation (c) HIV status/exposure (4) Gestational trophoblastic disease with (d) Pap test history of abnormal persistently elevated hCG levels or results malignant disease (e) Heavy menses/anemia (5) Cervical cancer prior to insertion and (f) Menstrual history awaiting treatment (2) Physical examination to include (6) Current breast cancer within past 5 (a) Speculum examination to as- years—LNG IUS only sess for possible vaginal/cervical (7) Any uterine anatomical abnormalities infection distorting uterine cavity incompatible (b) Pap test (if none within past year) with IUC insertion (c) Cervical cultures/wet prep (if (8) Current PID, purulent cervicitis, chla- history/physical examination mydia, or gonorrhea—initiation but indicates) not continuation (d) Bimanual examination—contour, (9) Endometrial cancer—initiation but size, consistency, mobility, posi- not continuation tion of uterus (10) Known pelvic tuberculosis—initiation (e) Hgb/Hct if history of anemia but not continuation b. Health assessment at follow-up visits b. Category 3 for IUC use—use of the (1) Speculum examination at first menses method not generally recommended for after insertion—check for IUD strings the following conditions unless other (2) Assessment for any signs/symptoms more appropriate methods are not avail- of pelvic infection able or acceptable: (3) Hgb/Hct if excessive bleeding (1) Ischemic heart disease occurring after c. Special considerations insertion—LNG IUS only (1) Timing of insertion (2) Migraine headache with aura starting (a) Not necessary to wait for menses after insertion—LNG IUS only if evidence that patient is not (3) Gestational trophoblastic disease with pregnant decreasing or undetectable hCG levels (b) May be inserted within 48 hours (4) History of breast cancer with no evi- after delivery (vaginal and dence of disease for 5 years—LNG IUS cesarean) only (c) May be inserted 4 or more weeks postpartum 60 Chapter 3 Women’s Health

(d) Insertion after 48 hours and be- (b) Patient requests abortion—re- fore 4 weeks postpartum is associ- move IUC and refer ated with increased risk of uterine (c) Patient wants to continue preg- perforation nancy—visible strings (e) May be inserted immediately fol- i. Advise concerning risk for lowing first or second trimester spontaneous abortion—de- abortion creased risk with IUC removal (2) Menstrual abnormalities (spotting, early in pregnancy bleeding) ii. Gently remove IUC (a) Nonsteroidal anti-inflammatory iii. Warning about possible drugs (NSAID) may reduce bleed- ectopic ing if initiated at start of menses (d) Patients wants to continue preg- (b) Hgb/Hct if excessive or prolonged nancy—no visible strings bleeding i. Advise concerning risk for i. Ferrous sulfate for 2 months if spontaneous abortion Hgb less than 11.5 g—repeat ii. Ultrasound to determine if Hgb/Hct at 3 months IUC present ii. Remove IUC if Hgb less than iii. Monitor for intrauterine in- 9 g—repeat Hgb/Hct 1 month fection throughout pregnancy (c) Assess for endometritis/PID if and retrieve IUC at delivery bleeding associated with pain iv. If intrauterine infection oc- i. Tests for chlamydia, gonor- curs refer for evacuation of rhea, and bacterial vaginosis uterus ii. Uterine tenderness (6) Perforation, embedding iii. Treat with antibiotics appro- (a) Perforation occurs 1 in 1,000 priate for PID if suspicious insertions (d) Persistent bleeding requires fur- i. May/may not be associated ther evaluation with severe pain at time of (e) Remove IUC if patient desires and insertion provide alternative contraception; ii. U/S to determine location— may consider switch to LNG IUS may require laproscopic if having excessive bleeding with removal CU 380T and wants to continue iii. If protrusion through cervix, IUC as method can be removed in office with (3) Cramping and pain local anesthetic (a) If severe—rule out perforation (b) Embedding (b) If mild—NSAID/other analgesic i. Can remove IUC from uterus or remove IUC with forceps if visualized (c) May indicate infection, pregnancy ii. May need to be removed (4) Expulsion—2 to 10% within first year with dilatation and curretage (a) Symptoms—cramping, spotting, (D&C) dyspareunia, lengthening of string (7) PID (b) Partial expulsion (a) Most IUC related PID occurs i. Remove IUC within the first 20 days after ii. Rule out pregnancy/infection insertion iii. Replace IUC if patient desires (b) No evidence supporting the use of iv. Doxycycline for 5 to 7 days prophylactic antibiotics to reduce (c) Complete expulsion post insertion infection i. Pregnancy test (c) Treat PID with appropriate ii. Replace IUC if patient desires antibiotics (5) Pregnancy (d) Not necessary to remove IUC un- (a) Spontaneous abortion (SAB) less has current high risk for STI i. Remove IUC (8) Actinomyces-like organisms on Pap ii. Doxycycline/ampicillin for 7 test days (a) Pap test does not diagnose actino- iii. Ferrous sulfate if anemic/ mycosis infection heavy bleeding (b) Actinomyces is normal female genital tract organism Fertility Control 61

(c) Pelvic actinomycosis is very rare 5. Disadvantages and side-effects but serious infection a. Coitally dependent (d) Asymptomatic—inform IUC user, b. Does not protect against STD/HIV no treatment necessary c. Potential for allergy/sensitivity/irritation (e) Symptomatic—endometritis d. Must follow instructions for effective use i. Treat with antibiotics—sensi- 6. Precautions and risks tive to penicillin and several a. Individuals with skin sensitivities may other antibiotics want to test/avoid use ii. Remove IUC—actinomyces b. Individual must be capable of following organism preferentially grows instructions for use on foreign bodies c. Vaginal abnormalities (septa, prolapse) 8. Instructions for using the method may preclude use a. Check IUD strings 7. Management (1) After each menses a. No health assessment needed prior to ini- (2) If increased cramping tiation of method (3) If absent—use backup birth control b. Special considerations and notify healthcare provider (1) Encourage use of spermicide with (4) If longer condom for increased effectiveness (a) May be in process of expulsion (2) Frequent use of spermicides (more (b) Use backup birth control and no- than two times a day) associated with tify healthcare provider vulvovaginal epithelium disruption b. Signs of infection—notify healthcare pro- and theoretically could increase sus- vider if ceptibility to HIV infection (1) Pelvic pain (3) CDC category 3 for women who have (2) Vaginal discharge HIV/AIDS (3) Unexplained vaginal bleeding 8. Instructions for using method c. Monitor menses—notify provider if any of a. Spermicide used with each act of the following: intercourse (1) Heavy, irregular bleeding b. All instructions read carefully (2) Missed menses—may have amenor- c. Spermicide left in place (no douching) for rhea with LNG IUS 6 hours following last intercourse (3) Increased cramping d. Instructions should be followed regarding d. Warning signs (PAINS) how long prior to intercourse the spermi- (1) Period late/missed; abnormal spot- cide may be inserted—if too much time ting or bleeding has lapsed, pregnancy may occur (2) Abdominal pain e. Spermicide placed deep within vagina (3) Infection—vaginal discharge f. Adequate time should be allowed for (4) Not feeling well—fever, aches, chills spermicide to dissolve (if film, tablets, or (5) String missing, shorter or longer suppositories) g. With foam use—canister should be shaken • Vaginal spermicides well, as directed, prior to filling applicator 1. Description—cream, foam, suppository, tablet, film, gel, or other preparation that destroys • Male condom sperm when placed in vagina 1. Description—latex/polyurethane/natural 2. Mechanism of action membranous sleeve placed over erect penis a. Nonoxynol-9 or octoxynol-9 is active prior to intercourse to prevent transmission of ingredient semen/sperm into vaginal vault b. Destroys sperm cell membrane 2. Mechanism of action—barrier; prevents trans- 3. Effectiveness/First year failure rate mission of semen/sperm into vagina a. Perfect use—6% 3. Effectiveness/First year failure rate b. Typical use—21% to 28% a. Perfect use—3% 4. Advantages b. Typical use—14% a. Accessible 4. Advantages b. Inexpensive a. Accessible c. Readily available backup method b. Cost-effective d. No systemic effects c. Prevents transmission of STD (except membrane condoms) 62 Chapter 3 Women’s Health

d. Active involvement of male partner 4. Advantages e. Prevents allergic reaction to semen a. Prevents transmission of STD f. Arrests development of antisperm anti- (1) Decreases risk of cervical dysplasia/ bodies in infertility patients neoplasia related to HPV g. May help prevent premature ejaculation (2) Decreases risk of PID and sequelae h. Does not require visit to healthcare due to decreased transmission of GC provider and chlamydia 5. Disadvantages and side-effects b. Does not require use of spermicide a. Decreased penile sensitivity c. Accessible b. Interrupts act of love making d. Controlled by the woman c. Not appropriate for men with erectile e. Does not require visit to healthcare dysfunction provider d. Requires active involvement of male 5. Disadvantages and side-effects partner a. Coitally dependent e. Possibility of condom rupture b. Noisy 6. Contraindications c. May be aesthetically unappealing a. Latex allergy (male or female partner)— d. Expensive use polyurethane 6. Precautions and risks b. Spermicide allergy (if condoms lubricated a. Must be properly inserted/positioned with spermicide) b. Polyurethane allergy 7. Management 7. Management a. No health assessment needed prior to ini- a. No health assessment needed prior to initiation of method tiation of method b. Special considerations b. Special considerations—women with (1) Membrane condoms may not protect vaginal abnormalities should not use this against STD/HIV method (2) Petroleum/oil based lubricants may 8. Instructions for using the method decrease effectiveness of latex con- a. Pouch held with open end down—inner doms (okay for polyurethane condom) ring should be at bottom of pouch 8. Instructions for using method b. Inner ring squeezed together and inner a. New condom used with each act of ring and pouch inserted into vagina intercourse c. Inner ring pushed deep into vagina b. Use water soluble lubricants with latex d. Outer ring should rest outside vulva condoms—KY jelly, Astroglide, Replens, e. Condom removed immediately after Lubrin intercourse c. Condom unrolled over penis completely f. Outer ring squeezed together and twisted (to the base) to prevent spillage d. Penis withdrawn from vagina soon after g. Discard the whole condom ejaculation—condom secured at base of h. New condom used with each act of penis to prevent spillage intercourse e. If condom slips/breaks i. Male condom should not be used when (1) Before ejaculation—apply new using female condom—may adhere to- condom gether causing dislodgement (2) After ejaculation—consider emergency contraception • Diaphragm 1. Description—reusable latex dome that covers • Female condom anterior vaginal wall, including cervix; sper- 1. Description—polyurethane sheath placed micide placed in dome covers cervix afford- in the vagina that acts as a barrier to pre- ing increased contraceptive protection; types vent direct contact with seminal fluid during include: intercourse a. Flat spring 2. Mechanism of action—barrier, protects (1) Good for women with firm vaginal vagina/vulva from direct contact with penis/ tone seminal fluid (2) Gentle spring strength 3. Effectiveness/First year failure rate b. Coil spring a. Perfect use—5% (1) Good for women with average vaginal b. Typical use—21% tone Fertility Control 63

(2) Firm spring strength (1) Health history to determine if special c. Arcing spring circumstances or contraindications (1) Good for women with lax vaginal tone (2) Vaginal examination to determine any (2) Firm spring strength abnormal anatomy that may preclude d. Wide seal proper fit and retention—prolapse, (1) Good for women with average/lax cystocele, rectocele, vaginal septum vaginal tone (3) Proper fit by trained professional— (2) Available as arcing or coil spring determine appropriate size and type 2. Mechanism of action for woman’s anatomy a. Barrier—prevents direct cervical contact b. Health assessment at follow-up visits—re- with seminal fluid check fit following childbirth or if patient b. Spermicide—nonoxynol-9/octoxynol-9 gains/loses 15 pounds or more destroys sperm cell membrane 8. Instructions for using the method 3. Effectiveness/First year failure rate a. General instructions (patient) a. Perfect use—6% (1) Insert just prior to intercourse or up to b. Typical use—20% 6 hours before 4. Advantages (2) Coat inner dome with 1 tablespoon of a. Cost effective—may be used for 1 to 2 spermicide years (3) Pinch sides of diaphragm and insert b. Affords some protection against STDs— fully into vagina possible decreased incidence of PID (a) Tuck anterior rim behind c. No systemic effects symphysis 5. Disadvantages and side-effects (b) Be certain that dome covers cervix a. Requires sizing by trained clinician and (4) If repeated intercourse, insert another instructions in use application of spermicide in vagina; b. May have sensitivity to latex/spermicide do not remove diaphragm c. Increased risk of bacterial vaginosis and (5) Leave diaphragm in place for at least 6 UTI hours following last intercourse (1) Due to increased colonization with (6) Do not leave in place for more than 24 E coli hours (2) Related to use of spermicide (7) After each use wash and store (3) Mechanical irritation/compression diaphragm in clean, cool, dark against urethra environment d. Does not afford absolute protection from (8) Do not use with oil-based lubricants STD/HIV or vaginal medications e. Risk of toxic shock—2 to 3/100,000 per (9) Replace diaphragm yearly year (10) Assess for holes/tears periodically by 6. Contraindications (CDC recommendations) filling with water and inspecting for a. Category 4 for diaphragm use leaks (1) Allergy to latex; does not apply to non- (11) Consider emergency contraception if latex diaphragms diaphragm is dislodged during or less (2) High risk for HIV—related to concerns than 6 hours after sex about frequent spermicide use dis- b. Warning signs (toxic shock) rupting vaginal epithelium rather than (1) High fever diaphragm (2) Nausea, vomiting, diarrhea b. Category 3 for diaphragm use—use of (3) Syncope, weakness method not generally recommended for (4) Joint/muscle aches the following conditions unless other (5) Rash resembling sunburn more appropriate methods are not available or acceptable: • Cervical cap (FemCap) (1) History of toxic shock syndrome 1. Description—reusable silicone cap, fits over (2) HIV/AIDS—related to concerns about cervix providing barrier contraception; sper- frequent spermicide use disrupt- micide placed in dome affords additional con- ing vaginal epithelium rather than traceptive efficacy; three sizes—22 mm, diaphragm 26 mm, 30 mm 7. Management 2. Mechanism of action a. Health assessment prior to initiation of a. Barrier—prevents direct cervical contact method with seminal fluid 64 Chapter 3 Women’s Health

b. Spermicide—nonoxynol-9/octoxynol-9 b. Health assessment at follow-up visits—re- destroys sperm cell membrane evaluate cap fit especially if patient com- 3. Effectiveness/First year failure rate plains of dislodgement during intercourse a. Perfect use c. Special considerations (1) Parous women—26% (1) Do not use less than 6 weeks postpar- (2) Nulliparous women—9% tum, immediate postabortion, or dur- b. Typical use ing menses (1) Parous women—40% (2) Not all women can achieve a good (2) Nulliparous women—20% cervical cap fit 4. Advantages (a) Cervix too short a. Cost-effective—may be used for 1 to 2 (b) Cap sizes not appropriate years (3) Efficacy significantly decreased in b. Affords some protection against STDs parous women c. Possible decreased incidence of PID 8. Instructions for using method d. Possible decreased incidence of cervical a. Insert cap at least 30 minutes prior to in- dysplasia/neoplasia tercourse to create suction e. No systemic effects b. Fill one third of cap with spermicide f. May be left in place for 48 hours c. Compress rim prior to insertion g. Does not require insertion of more sper- d. Advance into vagina so rim can slide over micide with repeat intercourse cervix h. Does not increase incidence of bladder e. Check that cap covers cervix infection f. Not necessary to reinsert spermicide with 5. Disadvantages and side-effects repeated intercourse a. Requires trained clinician for sizing g. Leave in place for at least 6 hours and no b. Sensitivity to silicone/spermicide more than 48 hours after sex c. Does not afford absolute protection h. Warning signs (toxic shock)—refer to dia- against STD/HIV phragm section d. Not every woman can be fitted appropriately • Lea’s shield e. May become dislodged during intercourse 1. Description—reusable oval-shaped silicone 6. Contraindications (CDC recommendations) device fits over cervix and part of upper vagina a. Category 4 for cervical cap use—high risk providing barrier contraception; airflow valve for HIV—related to concerns about fre- lets air between cervix and shield escape, cre- quent spermicide use disrupting vaginal ating a seal between shield and vagina; flexible epithelium rather than the cervical cap ring used to help with removal; spermicide b. Category 3 for cervical cap use—use of placed inside device affords additional contra- method not generally recommended for ceptive efficacy; one size the following conditions unless other 2. Mechanism of action more appropriate methods are not avail- a. Barrier—prevents direct cervical contact able or acceptable: with seminal fluid (1) HIV/AIDS—related to concerns about b. Spermicide—nonoxynol-9/octoxynol-9 frequent spermicide use disrupting destroys sperm cell membrane vaginal epithelium rather than the 3. Effectiveness/First year failure rate cervical cap a. Perfect use—8% (2) History of toxic shock syndrome b. Typical use—no information 7. Management 4. Advantages a. Health assessment prior to initiation of a. No fitting required—one size fits all method b. Reusable—good for about 6 months (1) Pap test within past year c. No systemic effects (2) Visualization of cervix to rule out d. May afford some protection against some abnormalities STDs (a) Extensive lacerations 5. Disadvantages and side-effects (b) Cervicitis a. Prescription required (c) Asymmetry b. Increased risk of bacterial vaginosis and (3) Palpation of cervix UTI (a) Length c. Does not afford absolute protection from (b) Position STD/HIV (c) Circumference Fertility Control 65

d. Potential risk of toxic shock—same as with c. May be used with male condom for addi- diaphragm tional contraceptive and STD protection e. May have sensitivity to silicone or 5. Disadvantages and side-effects spermicide a. Does not afford absolute protection form 6. Contraindications (CDC recommendations STD/HIV not specifically provided)—considered same b. Significant decrease in efficacy for parous as for diaphragm and cervical cap women versus nulliparous woman 7. Management c. Potential risk of toxic shock—same as with a. No health assessment needed prior to ini- diaphragm tiation of method d. May have sensitivity to polyurethane or b. Special considerations spermicide (1) Abnormal vaginal anatomy—pro- 6. Contraindications (CDC recommendations lapse, cystocele, rectocele may pre- not specifically provided)—consider same as vent proper placement for diaphragm and cervical cap (2) Do not use if delivery within past 6 7. Management weeks, recent abortion, or vaginal a. No health assessment needed prior to ini- bleeding tiation of method 8. Instructions for using the method b. Special considerations a. Apply spermicide around rim of shield (1) Abnormal vaginal anatomy—pro- b. Fold shield and insert as high in vagina as lapse, cystocele, rectocele may pre- possible vent proper placement c. Check that cervix is covered by shield (2) Do not use if delivery within past 6 d. Leave in place for 6 hours following weeks, recent abortion, or vaginal intercourse bleeding e. Use additional spermicide in vagina if re- 8. Instructions for using the method peat intercourse a. Moisten sponge with tap water prior to f. Do not leave in place more than 40 hours use g. Consider emergency contraception b. Insert deep into vagina if shield becomes dislodged during c. Check to be sure cervix is covered by intercourse sponge (1) After use wash with soap and water d. Leave in place for at least 6 hours after last and air dry intercourse (2) Replace every 6 months e. If repeated intercourse no additional sper- (3) Warning signs (toxic shock)—see Dia- micide needed phragm section f. Do not wear the sponge for more than 24 to 30 hours • Contraceptive sponge g. Discard sponge after use 1. Description—small pillow-shaped polyurethane sponge containing 1 g of nonoxynol-9 • Fertility awareness methods spermicide, concave side fits over cervix, poly- 1. Description—method of contraception using ester loop facilitates removal, one size abstinence during estimated fertile period 2. Mechanism of action based on all or some of the following methods a. Barrier—prevents direct cervical contact a. Menstrual cycle pattern (calendar with seminal fluid method) b. Spermicide—nonoxynol-9 destroys sperm b. Basal body temperature (BBT)—deter- cell membrane mines ovulation 3. Effectiveness/First Year Failure Rate c. Evaluation of cervical mucus (ovulation/ a. Perfect use Billings method)—determines ovulation (1) Nulliparous—9% d. Sympto-thermal method—combines BBT (2) Parous—20% with evaluation of cervical mucus and cer- b. Typical use vical position/consistency (1) Nulliparous—16% e. Standard days method—consider self fer- (2) Parous—32% tile days 8 through 19 of each menstrual 4. Advantages cycle a. No prescription required 2. Mechanism of action—intercourse is avoided b. No systemic effects during fertile period a. Ovum remains fertile for 24 hours 66 Chapter 3 Women’s Health

b. Sperm viability approximately 72 hours (1) Keep record of menstrual cycle inter- c. Most pregnancies occur when intercourse vals for several months occurs before ovulation (2) From the shortest cycle length, sub- 3. Effectiveness/First year failure rate tract 18 days—this determines first a. Perfect use fertile day (1) Calendar method—9% (3) From the longest cycle length, sub- (2) BBT—2% tract 11 days—this determines last (3) Ovulation method—3% fertile day (4) Sympto-thermal—2% (4) Use these numbers to determine days (5) Standard days method—5% of abstinence for every cycle b. Typical use for all methods—25% b. Basal body temperature (BBT) method 4. Advantages (1) Take temperature each morning be- a. Minimal cost fore rising b. Natural (a) BBT thermometer (1) No systemic effects (b) Temperature can be oral, vaginal, (2) No localized side-effects, e.g., latex or rectal (maintain same route) allergy (2) Record on BBT chart c. Can be utilized for contraception and con- (3) Temperature increase of 0.4°F or ception planning higher at ovulation—remains elevated 5. Disadvantages and side-effects for at least 3 days a. Requires motivation from both partners (4) Abstain from intercourse until 3-day b. Requires periodic abstinence temperature increase occurs c. No protection against STD/HIV c. Ovulation method 6. Precautions and risks (1) Inspect cervical mucus/secretions on a. Not reliable for women with the following underwear, toilet tissue with fingers, conditions: beginning day after menses (1) Irregular menses (consider sympto- (2) Determine consistency—elastic, thermal and ovulation methods) slippery, wet by touch indicates pre- (2) Perimenopausal ovulatory (3) Recently postpartum (a) Amount increases; becomes thin- (4) Have had recent menarche ner and more elastic around time b. Not a suitable method for of ovulation (1) Women who cannot accurately evalu- (b) After ovulation, mucus becomes ate their fertile period thick, tacky, and cloudy (a) Inability to use/read thermometer (3) Abstain from intercourse during “wet (b) Inability to understand cervical days” at onset of increased, slippery, mucus/changes thin mucus discharge until 4 days (c) Inability to time intercourse based past the peak day (last day of clear, on calendar evaluation stretchy, slippery secretions) (2) Couples unwilling to abstain during (4) Abstain from intercourse during men- fertile time period ses due to inability to assess mucus (3) If nonconsensual coitus is likely to d. Sympto-thermal method—combines ovu- occur lation, BBT, and assessment of 7. Management consistency/position of cervix in vagina a. Health assessment prior to initiation of (1) Uses cervical assessment method and method BBT (1) History to reflect pattern of menses (2) Ovulatory pain “mittelschmertz” may (2) Evaluation of client’s willingness/ be indicator ability to check cervical mucus/ (3) Abstain until latter of two methods consistency/position indicates “safe” time b. Health assessment at follow-up visits— e. Standard days method BBT/sympto-thermal chart evaluation (1) Abstain from intercourse days 8 c. Special considerations—combination of through 19 of each menstrual cycle fertility awareness methods more effective (2) CycleBeads are color coded string of than single method beads to help woman keep track of 8. Instructions for using the method cycle days a. Calendar method Fertility Control 67

• Lactational amenorrhea method (1) Menses 1. Description—method of contraception for (2) Regular supplementation is being women who are breastfeeding without supple- used mentation or with minimal supplementation (3) Long periods without breastfeeding and have not had a postpartum menstrual (4) Baby is 6 months old cycle c. Ovulation may occur before onset of 2. Mechanism of action—high prolactin menses a. FSH normal; LH decreased—no ovarian follicular development • Coitus interruptus (withdrawal) b. Inhibits pulsatile GnRH 1. Description—contraceptive method whereby c. Results in anovulation male withdraws penis from vagina prior to 3. Effectiveness/First year failure rate ejaculation a. Perfect use—0.5% to 1.5% (if amenorrheic) 2. Mechanism of action—no contact between b. Typical use—data not available sperm and ovum 4. Advantages 3. Effectiveness/First year failure rate a. Temporary a. Perfect use—4% b. No cost b. Typical use—19% c. Highly effective until infant nutritional 4. Advantages requirements mandate supplementation a. Requires no devices (approximately 6 months) b. No systemic effects d. Not coitally dependent c. No expense e. Advantageous for infant d. May result in decreased transmission of (1) Nutritional HIV (man to woman) (2) Bonding 5. Disadvantages and side-effects f. Requires no devices a. Requires self-control on part of male g. Minimal systemic effects partner 5. Disadvantages and side-effects b. Requires ability to predict time of a. Woman must breastfeed completely or ejaculation with minimal supplementation—may lead c. Does not afford protection from STD to exhaustion 6. Precautions and risks—should not be used by b. Decreased estrogen due to absence of fol- men with premature ejaculatory disorder licular development 7. Management (1) Atrophic vaginitis a. No health assessment needed prior to ini- (2) Decreased vaginal lubrication tiation of method (3) Dyspareunia b. Special considerations c. Affords no protection against STD/HIV (1) In itself, preejaculatory fluid contains 6. Precautions and risks no sperm a. Efficacy decreases with resumption of (2) If multiple acts of coitus occur, effi- menses cacy is decreased as subsequent pre- b. Must breastfeed completely or with mini- ejaculatory fluid may have “carry mal supplementation over” sperm from previous ejaculation 7. Management 8. Instructions for using the method a. No health assessment needed prior to ini- a. Male partner should void prior to tiation of method intercourse b. Special considerations—should not use b. Penis is withdrawn prior to ejaculation— vaginal estrogen cream to treat atrophic ejaculation occurs away from vaginal area vaginitis c. Repeated orgasms may result in presence (1) Absorption can inhibit milk of sperm in preejaculatory fluid production (2) Recommend use of vaginal lubricants • Abstinence 8. Instructions for using the method 1. Description—contraception based on ab- a. Minimal or no supplementation should be staining from penile–vaginal or penile–rectal used contact b. Alternative contraceptive method should 2. Mechanism of action—no possibility of con- be considered when any of the following ception as genital contact does not occur occur 3. Effectiveness/First year failure rate 68 Chapter 3 Women’s Health

a. Perfect use—0% b. Reversal is difficult, expensive and, often, b. Typical use—data not available unsuccessful 4. Advantages c. No protection against STD/HIV a. No cost d. Initially expensive b. No side-effects 6. Precautions and risks c. Protection against sexually transmitted a. Surgical procedure diseases (1) Operative complications—bladder/ 5. Disadvantages—requires motivation and ac- uterine/intestinal injury may occur ceptance by both partners (2) Anesthetic complications—death 6. Precautions and risks—couples should refrain (rare) from alcohol/drug use to “stay in control” b. Wound infection 7. Management—no health assessment needed c. If pregnancy occurs following procedure, prior to initiation of method increased risk of ectopic 8. Instructions for using the method 7. Management a. Avoid any penile–vaginal/rectal contact a. Health assessment prior to initiation of b. Consider alternative means of intimacy/ method sexual expression, e.g., mutual (1) Assess if patient candidate for surgery masturbation (2) Assess psychological readiness for c. Avoid alcohol or drug use; may affect com- permanent contraceptive method mitment to method b. Health assessment at follow-up visits— assess for signs/symptoms of infection • Female sterilization (1) Fever 1. Description—permanent contraception for (2) Wound tenderness woman achieved through surgical means; (3) Wound drainage commonly performed on outpatient basis or (4) Abdominal pain postpartum prior to discharge c. Special considerations 2. Mechanism of action (1) Consent form signed in advance a. Fallopian tubes are obstructed to prevent (2) Patient should be advised procedure union of sperm and ovum is irreversible b. Transabdominal—laparoscopy or mini- 8. Instructions for using the method laparoscopy approach; general or local a. Nothing by mouth at least 8 hours prior to anesthesia procedure (1) Surgical ligation—Pomeroy procedure b. Need transportation assistance from (2) Surgical ligation and attachment to hospital/clinic to home uterine body—Irving procedure c. Rest for at least 24 hours recommended (3) Electrocauterization following procedure (4) Section of tube excised d. Light lifting only for 1 week (a) Pritchard procedure e. No coitus for 1 week (b) Fimbriectomy f. Continue another method of contracep- (5) Occluded—compressed with silastic tion for 3 months after Essure insertion band (Falope Ring) or clip (Filshie) g. Confirm correct placement and tubal c. Transcervical (Essure) occlusion with hysterosalpingogram 3 (1) Micro-insert device inserted in tubes months after Essure insertion transcervically through hysteroscope h. Warning signs (notify healthcare provider) (2) Office procedure with local anesthesia (1) Fever greater than 100°F 3. Effectiveness/First year failure rate (2) Severe pain a. Perfect use—0.5% (3) Drainage from incision b. Typical use—0.5% (4) Dizziness/fainting/vertigo 4. Advantages a. Affords permanent contraception • Male sterilization b. Highly effective 1. Description—permanent contraception in- c. Cost-effective over long term volving occlusion of vas deferens, preventing d. Not coitally dependent transmission of sperm through semen 5. Disadvantages and side-effects a. Surgical resection—surgical incision made a. Invasive surgical procedure requiring in scrotum; vas deferens is resected anesthesia Fertility Control 69

b. Occlusion—surgical incision made in 12 weeks; obtain semen analysis to con- scrotum; vas deferens is divided and firm azospermia fulgurated/tied/cauterized g. Warning signs c. No scalpel—ring forceps secures vas def- (1) Fever greater than 100°F erens; dissecting forceps punctures skin (2) Increasing pain of scrotum; vas deferens lifted out and (3) Increasing swelling/tension on occluded stitches 2. Mechanism of action—sperm not present in (4) Bleeding/drainage from incision ejaculate 3. Effectiveness/First year failure rate • Future methods a. Perfect use—0.10% 1. IUC—smaller size, frameless b. Typical use—0.15% a. Less cramping 4. Advantages b. Lower expulsion rates a. Cost-effective 2. Hormonal methods—lower hormone doses, b. Highly effective improved progestins for all delivery routes c. Affords permanent contraception a. Improved safety d. Not coitally dependent b. Improved bleeding patterns e. No systemic effects/artificial devices 3. Spermicidal agents—formulations with micro- 5. Disadvantages and side-effects bicidal properties a. Initial expense 4. Barrier methods—designed to accommodate b. Should be considered irreversible spermicides with microbicidal properties c. Invasive surgical procedure 5. Male hormonal options d. No protection against STD/HIV a. Weekly testosterone enanthate injection 6. Precautions and risks b. Testosterone implants a. Surgical procedure 6. Immunocontraceptives b. Wound infection a. Female—hCG vaccine; abortifacient 7. Management b. Male—follicle stimulating hormone/ a. Health assessment prior to initiation of luteinizing hormone releasing hormone procedure—assess psychological readi- (FSH/LHRH) vaccine ness for permanent contraceptive method b. Health assessment at follow-up visits— • Abortion assess for signs/symptoms of infection 1. Medication abortion (1) Fever a. Mifepristone plus misoprostol (2) Wound tenderness (1) Most effective at 7 weeks’ gestation or (3) Wound drainage earlier (4) Swelling (a) 95% effective at 7 weeks LMP or c. Special considerations earlier (1) Relationship between vasectomy and (b) 80% effective in the ninth week prostate cancer unclear LMP (a) Study data conflicting (2) Mifepristone (b) Prostate screening postvasectomy (a) 19 norsteroid is same as for men in general (b) Progesterone antagonist population (3) Misoprostol—prostaglandin analogue (2) Procedure does not confer immediate (4) Method requires two clinic visits sterility—up to 20 ejaculations will (a) Mifepristone orally at initial visit contain sperm (b) Misoprostol vaginally or buc- 8. Instructions for using the method cally at home 24 to 72 hours after a. Rest recommended for approximately 48 mifepristone hours following procedure (c) 1 to 2 week follow-up appoint- b. Apply ice pack to scrotum for minimum of ment to assess for complete 4 hours after procedure abortion c. Avoid lifting/exercise for minimum of 1 (d) May repeat misoprostol or pro- week vide aspiration if abortion is not d. Keep area dry for 48 hours complete at 1 week e. Abstain from intercourse for 48 hours (e) Aspiration abortion if pregnancy f. Continue using other contraception until persists 2 weeks after initiation of minimum of 20 ejaculations/ medication abortion 70 Chapter 3 Women’s Health

b. Methotrexate plus misoprostol d. Tissue examined to rule out molar (1) 95% effective in early pregnancy pregnancy (2) Methotrexate 5. Potential postabortion complications (a) Destroys trophoblastic tissue a. Infection (b) Blocks folic acid preventing cell b. Retained products of conception division c. Trauma to uterus/cervix (3) Two clinic visits d. Excessive bleeding (a) Methotrexate IM at initial visit e. Warning signs (b) Misoprostol vaginally or buccally (1) Fever at home 3 to 7 days later (2) Persistent/increasing lower abdomi- (c) Follow-up appointment same as nal pain with mifepristone—misoprostol (3) Prolonged/excessive vaginal bleeding regimen (4) Purulent vaginal discharge (4) Avoid use of folic acid during pro- (5) No return of menses within 6 weeks cedure; may inhibit action of methotrexate Â Questions 2. Surgical methods a. Vacuum aspiration (first trimester) Select the best answer. (1) Suction curretage (2) Local anesthetic 1. Which of the following lab values would be b. Dilation and evacuation (D&E)—can be expected with menopause? performed up to 20 weeks’ gestation 3. Pre-abortion health assessment and a. Decreased FSH, increased LH, decreased counseling estradiol a. History b. Decreased LH, increased FSH, increased (1) LMP and menstrual history estradiol (2) Surgical history including gynecologi- c. Increased FSH, increased LH, decreased cal surgeries estradiol (3) Contraceptive history d. Increased LH, decreased FSH, increased (4) Medical history estradiol (5) Current medications/history of aller- 2. According to the North American Menopause gic responses Society, a 45-year-old female presenting for a b. Physical examination routine annual exam should have which of the (1) Size of uterus following screening tests? (2) Note uterine/cervical position (3) Presence of uterine/cervical/adnexal a. Pap test, plasma glucose, thyroid function abnormalities test (a) Fibroids b. Plasma glucose, Pap test, mammography (b) Adnexal masses (rule out ectopic) c. Stool for occult blood, mammography, Pap (4) Laboratory tests test (a) Pregnancy test—urine/serum d. Thyroid function test, mammography, (b) Hgb/Hct sigmoidoscopy (c) Blood type and Rh 3. The most prevalent contraceptive method (d) STD evaluation if warranted, e.g., among married women in the United States is: sexual assault/patient concern c. Counseling a. Combination oral contraceptives (1) Discuss all pregnancy options b. Condoms (2) Discuss options for termination— c. Sterilization medication, surgical d. Withdrawal 4. Postabortion health assessment and 4. A 54-year-old female with vaginal dryness counseling causing irritation and dyspareunia has no a. Contraceptive counseling problem with hot flashes and has a bone densi- b. Rh immunization if patient Rh negative— tometry T score of 1.0. The best treatment for give at first visit with medication abortion her would be: c. Prophylactic antibiotics may be given to surgical patients a. Continuous combined regimen HT b. Cyclic HT with added testosterone Questions 71

c. Estrogen vaginal ring a. Cervical os d. Progestin-only therapy b. Columnar epithelium c. Squamous epithelium 5. An advantage of continuous-combined HT over d. Transformation zone continuous-cyclic HT regimens is: 12. The portion of the uterus that is shed during a. No estrogen-free period during which vaso- menstruation is the: motor symptoms can occur b. Predictable withdrawal bleeding each month a. Endometrium c. Lower cumulative dose of progestin b. Myometrium d. Less negative impact on triglyceride levels c. Omentum d. Pyometrium 6. Which of the following women should have an endometrial biopsy/evaluation? 13. Estrogen is released by the ovary in response to: a. Woman on continuous-cyclic HT regimen a. FSH with amenorrhea b. GnRH b. Woman on continuous-cyclic HT regimen c. hCG with bleeding starting last few days of pro- d. LH gestin administration each month 14. Which of the following is the least potent c. Woman on continuous-combined HT endogenous estrogen? regimen with irregular bleeding in the first year of use a. Estradiol d. Woman on continuous-combined HT b. Estriol regimen with spotting that occurs after c. Estrone several months of amenorrhea d. Estropipate 7. The sebaceous glands located within the areola 15. Which of the following hormones is responsible are called: for regulating sodium and potassium by the kidneys? a. Bartholin’s glands b. Cowper’s glands a. Aldosterone c. Montgomery’s glands b. Androstenedione d. Skene’s glands c. Cortisol d. DHEA 8. The shift in vaginal pH that occurs during puberty is influenced by: 16. Which phase of the menstrual cycle is the most variable? a. Estrogen b. FSH a. Follicular c. LH b. Luteal d. Progesterone c. Ovarian d. Secretory 9. A vaginal pH less than 4.5 is an expected finding: 17. Which hormone is dominant during the prolif- a. In a healthy reproductive age woman erative phase of the menstrual cycle? b. In a menopausal woman with atrophic vaginitis a. Estrogen c. In a reproductive-age woman with b. LH trichomoniasis c. Progesterone d. In a healthy prepubertal-age girl d. Prolactin 10. The predominant vaginal organism responsible 18. Which population is at increased risk for having a for normal pH in reproductive-age women is: mutation of the breast cancer gene (BRCA1/2)? a. Doderlein bacilli a. African Americans b. Gardnerella b. Ashkenazic Jews c. Haemophilus c. Asians d. Lactobacilli d. Hispanics 11. Squamous metaplasia of the cervix occurs within 19. The minimum conjugated estrogen dose that has the: been shown to prevent osteoporosis in menopausal women is: 72 Chapter 3 Women’s Health

a. 0.3 mg a. She most likely was not adequately treated b. 0.625 mg for her primary syphilis 1 year ago. c. 0.9 mg b. She has most likely become reinfected since d. 1.25 mg her treatment 1 year ago. c. She most likely has some other condition 20. A 53-year-old female who had a hysterectomy that is causing a false positive FTA-ABS. 10 years ago for dysfunctional uterine bleeding d. She most likely was treated adequately for presents with complaints of severe hot flashes her syphilis and has not become reinfected. and night sweats for the past few months. Her lipid profile is significant for cholesterol of 220 26. When evaluating cervical mucus, the term spinn- mg/dL and triglycerides of 350 mg/dL. The most barkeit refers to: appropriate therapy for her vasomotor symp- a. Amount toms at this time would be: b. Cellularity a. Continuous-combined oral HT c. Clarity b. Selective estrogen receptor modulator d. Elasticity (raloxifene) 27. A 24-year-old female presents to your office with c. Transdermal estrogen patch a request for combination oral contraceptives. d. Vaginal estrogen cream Her current medications include a bronchodilator 21. Which of the following estrogen replacement for asthma. Management for this client should options does not require opposition by a pro- include advising her that: gestin in a woman with an intact uterus? a. Combination oral contraceptives are not rec- a. Bioidentical oral estrogen formulation ommended for women with asthma. b. Estring vaginal ring b. Combination oral contraceptives may poten- c. Plant based (estriol) oral estrogen tiate the action of her bronchodilator. d. Transdermal estrogen patch c. She should use a backup method if using the bronchodilator several days in a row. 22. Adding potassium hydroxide to a wet mount d. Use of progestin-only contraceptive injec- slide before viewing it under the microscope is tions may reduce her asthma attacks. useful in the detection of: 28. Which of the following contraceptive methods a. Clue cells would be best for a woman with a seizure dis- b. Candida pseudohyphae order who is taking phenytoin? c. Trichomonads d. White blood cells a. Combination oral contraceptives b. Transdermal contraceptive patch 23. Which of the following statements concerning a c. Progestin-only oral contraceptives beta subunit radioimmunoassay (RIA) pregnancy d. Progestin-only contraceptive injections test is true? 29. A client calls the clinic on Tuesday morning. She a. It is most commonly used for qualitative hCG had unprotected sex Friday night and is inter- determination ested in emergency contraception. Appropriate b. It can be performed on either urine or blood information for this client would include: c. Cross-reaction with FSH or LH may occur during perimenopause a. Emergency contraception pills are very effec- d. It is reliable 7 to 10 days postconception tive for medical abortion in early pregnancy. b. If she is not midcycle when she had sex, she 24. The American Cancer Society recommends yearly does not need emergency contraception. mammogram screening beginning at age: c. It is too late for emergency contraceptive a. 35 pills, but insertion of an IUC is an option. b. 40 d. She can use emergency contraception pills c. 45 even if she has had other unprotected sex d. 50 since her last period. 25. A woman who was treated for primary syphilis 30. The levonorgestrel-containing IUC may be a 1 year ago now has the following test results: better choice than the copper-containing IUC for VDRL nonreactive and FTA-ABS positive. These a woman who: findings indicate: Questions 73

a. Has never been pregnant c. Nonsteroidal anti-inflammatory drugs

b. Has dysmenorrhea d. Vitamin B6 supplements c. Is currently breastfeeding 37. Potential disadvantages of progestin-only d. Is sure she does not want more children implants (Implanon) include: 31. A 28-year-old female who has had an IUC for 2 a. May have increased side-effects in women years has a Pap test showing actinomycosis. She who are underweight has no symptoms of infection. Appropriate man- b. May cause a significant decrease in bone agement would include: mineral density a. Removing the IUC and repeating the Pap test c. May cause irregular bleeding and spotting in 6 months d. Return to fertility after discontinuation can b. Removing the IUC, treating with doxycycline may take several months and repeating the Pap test in 1 year 38. On the average, cognitive development is com- c. Keeping the IUC and repeating the Pap test pleted with the formation of formal operational in 1 year thought by age: d. Keeping the IUC, treating with doxycycline and repeating the Pap test in 3 months a. 12 b. 14 32. Which of the following diaphragms would be c. 16 best for a woman with very firm vaginal tone? d. 18 a. Arcing spring 39. Which endogenous estrogen is known as the b. Coil spring “estrogen of pregnancy”? c. Flat spring d. Wide seal a. Estradiol b. Estriol 33. The type of skin lesion seen initially with toxic c. Estrone shock syndrome is: d. Estropipate a. Diffuse sunburn-like rash 40. Increased production of _____ is associated with b. Multiple vesicles on chest and extremities primary dysmenorrhea. c. Petechiae on mucomembranous tissues d. Ulcerative lesions in genital area a. Androstenedione b. Arachidonic acid 34. Advantages of the cervical cap over the dia- c. Cortisol phragm include: d. Prostaglandin a. It is has a lower failure rate. 41. The optimal time each month for self-breast b. It is easier to insert. examination is: c. It can remain in place for 48 hours. d. Spermicide is not needed. a. A few days before expected menses b. At approximately midcycle 35. Which of the following statements concerning c. During the first 1 to 3 days of menses a transcervical (Essure) sterilization procedure is d. 1 to 7 days after the end of menses correct? 42. Which of the following is not an FDA-approved a. The fallopian tubes are occluded with a indication for the use of hormone therapy (HT)? silastic band. b. The success of reversals is higher than with a. Prevention of cardiovascular disease other sterilization methods. b. Prevention of osteoporosis c. It is effective within 1 to 2 weeks after the c. Relief of moderate-to-severe symptoms of procedure. vaginal atrophy d. The patient needs to return for a hystosal- d. Relief of moderate-to-severe vasomotor pingogram 3 months after the procedure. symptoms 36. A woman who is undergoing a medically induced 43. Although not an approved indication, studies abortion using methotrexate and misoprostol have indicated that HT may have the benefit of should be advised to avoid which of the fol- decreasing the risk for: lowing during the procedure? a. Colon cancer a. Acetaminophen b. Major depression b. Folic acid supplements 74 Chapter 3 Women’s Health

c. Osteoarthritis c. The woman can rely on this method as long d. Ovarian cancer as she is not having periods. d. Another method of contraception should be 44. A woman who is requesting contraception and considered when the infant begins sleeping who also wants to get pregnant in 1 year should through the night. avoid using: 49. The woman in question #48 asks if she can a. Combination oral contraceptives restart birth control pills while she is still breast- b. Fertility awareness methods feeding. The best response would be: c. Progestin-only oral contraceptives d. Progestin-only contraceptive injections a. Combination oral contraceptives are contraindicated during the duration of 45. A woman plans to use the calendar method for breastfeeding. contraception. She has charted her menstrual b. All hormonal methods of contracep- cycles for several months and has noted her tion should be avoided while she is longest cycle to be 30 days and her shortest cycle breastfeeding. to be 27 days. She should abstain from sexual c. She should wait until she is having regular intercourse each cycle from day ___ through day periods before restarting her birth control ___. pills. a. 9; 19 d. Progestin-only pills may be a better option b. 10; 15 for her to start at 6 weeks postpartum. c. 11; 18 50. A woman using a diaphragm for contraception d. 12; 16 has sexual intercourse at 8:00 a.m. on Friday, at 46. Which of the following statements by a client 2:00 a.m. on Saturday and again at 8:00 a.m. indicates she needs additional information about on Saturday. When can she safely remove her use of the contraceptive vaginal ring? diaphragm for effective contraception while minimizing problems related to leaving the dia- a. I should insert a new ring every 7 days. phragm in for extended periods of time? b. I should expect to have regular periods while using the ring. a. 10:00 a.m. on Saturday c. My partner can use a male condom while I b. 2:00 p.m. on Saturday am wearing the ring. c. 10:00 p.m. on Saturday d. The exact position of the ring in the vagina is d. 8:00 a.m. on Sunday not important. 51. An individual who either has active hepatitis B 47. According to CDC initiating progestin-only con- infection or who is a carrier would have a posi- traceptive injections (DMPA) is a Category 3 tive test for: when which of the following conditions exists? a. Hepatitis B surface antigen a. Age 35 years or older and smoking more b. Hepatitis B surface antibody than 15 cigarettes daily c. Hepatitis B e-antigen b. History of deep vein thrombosis or pulmo- d. Hepatitis B e-antibody nary emboli 52. Which of the following statements is true con- c. Unexplained vaginal bleeding prior to cerning rapid HIV tests when compared with EIA evaluation blood test sent to a lab? d. Use of drugs that alter liver enzymes a. It may take longer after exposure for rapid 48. A 4-week postpartum woman who is breast- HIV test to be positive. feeding presents in your office to discuss her b. Positive results of rapid HIV test are defini- contraceptive options. Currently she is breast- tive, so a confirmatory test is not necessary. feeding on demand and is not providing any c. Rapid HIV screening tests have not been FDA supplements. She plans to continue breast- approved. feeding for at least 6 months. Information for d. Sensitivity of both types of tests is the same. this woman concerning the lactational amenorrhea method of contraception should include: 53. A 58-year-old female has a bone densitometry test with the results of T-score –2.0. This indicates a. The expected failure rate for this method of the following: contraception is about 20%. b. This method is considered effective for only 3 a. She has bone density that is greater than months postpartum. that of most women her age. Questions 75

b. She has bone density that is equal to that of 4 situation for the indicated contraceptive a young normal adult. method? c. She has bone loss that is at the level for a a. Levonorgestrel-containing IUC for woman diagnosis of osteopenia. with endometriosis d. She has bone loss that is at the level for a b. Copper-containing IUC for woman with diagnosis of osteoporosis. history of breast cancer 54. The gold standard test for herpes simplex virus is: c. Progestin-only pills for woman with past history of deep vein thrombosis a. Pap test d. Vaginal contraceptive ring for woman older b. Tissue culture than 35 years of age who smokes 1 ppd c. Type-specific serologic tests d. Tzanck test 61. An advantage of the female condom is: 55. The anatomical area that contains the urethral/ a. It can be used with a male condom for added vaginal openings, hymen, Skene’s glands and protection. Bartholin glands is called the: b. It can be used for repeated acts of intercourse. a. Labia majora c. It may be used by individuals with latex b. Perineum allergy. c. Vestibule d. It has a lower failure rate than the male d. Vulva condom. 56. Findings on a pelvic examination of a 25-year-old 62. Noncontraceptive benefits of combination female include uterus 7 cm in length, right ovary oral contraceptives include all of the following 3 cm 3 2 cm, and left ovary nonpalpable. These except: findings indicate a/an: a. Decrease in risk for benign breast disease a. Normal uterus, normal ovaries b. Decrease in risk for cervical cancer b. Normal uterus, enlarged right ovary c. Decrease in risk for endometrial cancer c. Enlarged uterus, normal ovaries d. Decrease in risk for ovarian cancer d. Enlarged uterus, enlarged right ovary 63. For which of the contraceptive methods is there 57. Which of the following occurs first during female the least difference between the perfect use and puberty? typical use failure rates? a. Beginning breast development a. Combination oral contraceptives b. Beginning pubic hair development b. Diaphragm c. Growth spurt c. Intrauterine device d. Menstruation d. Male condom 58. Which of the following structures produces 64. A woman who weighs 200 lbs or greater may gonadotropin releasing hormone (GnRH)? have decreased effectiveness with which of the a. Anterior pituitary gland following contraceptive methods? b. Hypothalamus a. Progestin-only injectable contraception c. Posterior pituitary gland b. Contraceptive vaginal ring d. Ovaries c. Levonorgestrel intrauterine system 59. Which of the following list of events is in the d. Transdermal contraceptive system correct chronological order? 65. A woman who is taking combination oral con- a. LH surge, ovulation, rise in BBT, thickened traceptives should be advised to use a backup cervical mucus method of contraception for 7 days if she: b. Ovulation, LH surge, thickened cervical a. Misses two pills in the second week of her mucus, rise in BBT pill pack c. Rise in BBT, thickened cervical mucus, ovula- b. Misses one pill in the third week of her pill tion, LH surge pack d. Thickened cervical mucus, rise in BBT, LH c. Starts her first pack of pills on the first day of surge, ovulation her period 60. According to CDC recommendations, which of d. Starts her first pack of pills using the Quick- the following would be considered a Category start method 76 Chapter 3 Women’s Health

66. A 20-year-old female who is 30% overweight 71. The menopausal woman may experience some presents for her first Depo Provera injection. changes in sensation or the orgasmic experience Concerns in administering Depo Provera to this during sexual activity related to: woman include: a. Decreased vasocongestion and decreased a. She may need a larger dose than the usual vaginal expansion 150 mg. b. Decreased vasocongestion and increased b. She should return for repeat injections every vaginal expansion 2 months. c. Increased vasocongestion and decreased c. You should massage the injection site well to vaginal expansion assure absorption. d. Increased vasocongestion and increased d. You should choose a site that assures deep vaginal expansion IM injection. 72. Which of the following contraceptive choices 67. Instructions for progestin-only oral contraceptive should not be recommended for the perimeno- users should include: pausal woman who is having irregular menses? a. If you are more than 3 hours late taking a a. Combination oral contraceptives pill, use a backup method for 48 hours. b. Diaphragm b. If two pills are missed in the third week of c. Fertility awareness methods the pack, throw away the pack and start a d. LNG intrauterine system new one. 73. Endocervical curettage is performed to evaluate c. If you miss pills in the fourth week of the abnormalities of the: pack, you do not have to use a backup method. a. Endometrial tissue d. If you miss two pills in the first week of b. Glandular epithelium the pack, make them up and use a backup c. Squamous epithelium method for 7 days. d. Transformation zone 68. A 65-year-old female currently on a cyclic HT 74. A 26-year-old female is planning to use basal regimen is at your office for a routine annual body temperatures for contraception. Which of examination. She states she has been healthy in the following statements would indicate that she the last year and is having no problems with HT. needs further instruction on this method? On bimanual examination, a 4-cm nontender a. I will take my temperature the same time right ovary is palpated. Appropriate manage- each day before getting out of bed. ment would include: b. I know that I am about to ovulate when my a. Discontinue HT and repeat the bimanual temperature rises at least 0.4 degrees. examination in 2 months c. I will need to use a special thermometer to b. Have her return in 1 year as this is a normal take my basal body temperature. finding for a 65-year-old woman d. A rise of 0.4 degrees above my baseline for 3 c. Refer her to a gynecologist for further days indicates it is safe to have sex. evaluation 75. The mechanism of action of mifepristone in d. Switch to a continuous HT regimen and reex- inducing abortion is: amine her in 2 months a. Antiprogesterone effect on the 69. The structure in the breast that is responsible for endometrium milk production is the: b. Cervical dilatation effect a. Areola c. Stimulatory effect on the myometrium b. Alveoli d. Toxic effect on the fertilized egg c. Lobule 76. Instructions/information for a new user of combi- d. Lactiferous sinus nation oral contraceptives should include: 70. The hormone that stimulates synthesis of milk is: a. Combination oral contraceptives may a. Aldosterone decrease the effectiveness of some b. Estrogen antibiotics. c. Progesterone b. Discontinue your pills immediately if you d. Prolactin miss a period. Answers 77

c. Start the first pack of pills on the last day of Â Answers your next period. d. Sunday starters should use a backup method â 1. c 41. d for the first week of the first pack of pills. â 2. b 42. a 77. The most commonly used method of deter- â 3. c 43. a mining bone density to establish a diagnosis of â 4. c 44. d osteoporosis or the need for preventive treat- â 5. c 45. a ment is: â 6. d 46. a a. Dual energy x-ray absorptiometry â 7. c 47. c b. Quantitative computerized tomography â 8. a 48. d c. Quantitative ultrasound â 9. a 49. d d. Single x-ray absorptiometry 10. d 50. b 78. Instructions for the use of nonoxynol-9 spermi- 11. d 51. a cide should include: 12. a 52. d 13. a 53. c a. Place spermicide close to the opening of the vagina for maximal effectiveness. 14. b 54. b b. Remove excess spermicide from vagina 15. a 55. c within 6 hours to reduce vaginal irritation. 16. a 56. a c. When used with a condom, spermicide will 17. a 57. a further decrease risk for STD. 18. b 58. b d. Frequent use of spermicide may cause 19. b 59. a vaginal changes making you more suscep- 20. c 60. d tible to HIV infection. 21. b 61. c 79. According to CDC recommendations, which of 22. b 62. b the following is considered to be a Category 4 23. d 63. c condition for use of the indicated contraceptive 24. b 64. d method? 25. d 65. d a. Use of emergency contraceptive pills by 26. d 66. d a woman who has history of deep vein 27. b 67. a thrombosis 28. d 68. c b. Insertion of IUC in a woman with a history of 29. d 69. b PID 30. b 70. d c. Use of combination oral contraception by a 31. c 71. a 40-year-old woman who has migraine headaches without aura 32. c 72. c d. Use of progestin-only pills by a woman who 33. a 73. b has diabetes type 2 34. c 74. b 35. d 75. a 80. Which of the following statements concerning coitus interruptus is not correct: 36. b 76. d 37. c 77. a a. It has a lower perfect use failure rate than 38. c 78. d the cervical cap. 39. b 79. c b. It may result in a decreased risk for HIV transmission to female partner. 40. d 80. d c. Men are typically not able to predict the timing of ejaculation. d. There is a decreased chance for the presence of preejaculatory sperm with repeat acts of intercourse. 78 Chapter 3 Women’s Health

Â Bibliography Hatcher, R., Trussell, J., Nelson, A. et al. (2007). Contra- ceptive technology (19th ed.). New York: Ardent Me- Altman, A., Moore, A., Speroff, L., and Wysocki, S. dia, Inc. (2009). Tackling the tricky issue of bioidentical hor- National Osteoporosis Foundation. (2008). Clinician’s mones. Women’s Health Care: A Practical Journal for guide to prevention and treatment of osteoporosis. Nurse Practitioners, 8(7), 7–15. Washington, DC: National Osteoporosis Foundation. American Cancer Society. (2008). How to perform breast Saslow, D., Runowicz, C., Solomon, D. et al. (2002). self examination. Retrieved on July 2009 from http:// American Cancer Society guideline for the early de- www.cancer.org/docroot/CRI/content/CRI_2_6x_ tection of cervical neoplasia and cancer. CA Cancer How_to_perform_a_breast_self_exam_5.asp?sitearea. Journal for Clinicians, 52(6), 342–362. American College of Obstetricians and Gynecologists. Seidel, H., Ball, J., Dains, J., & Benedict, W. (2006). Mos- (2009). Cervical cytology screening. ACOG Practice by’s guide to physical examination (6th ed.). St. Louis: Bulletin, (109), 1–12. Mosby, Inc. Centers for Disease Control and Prevention. (2010). Smith, R., Saslow, D., Sawyer, K. et al. (2003). American U.S. medical eligibility criteria for contraceptive use. Cancer Society guidelines for breast cancer screen- Morbidity and Mortality Weekly Report, 59(Early Re- ing: Update 2003. CA Cancer Journal for Clinicians, lease), 1–6. 53(3), 141–169. Centers for Disease Control and Prevention. (2006). Tharpe, N., & Farley, C. (2009). Clinical practice guide- Sexually transmitted diseases treatment guidelines. lines for midwifery and women’s health. Sudbury, MA: Morbidity and Mortality Weekly Report, 55(RR11), Jones and Bartlett. 1–100. The North American Menopause Society. (2007). Meno- Chernecky, C., & Berger, B. (2008). Laboratory tests and pause practice: A clinician’s guide (3rd ed.). Cleveland, diagnostic procedures (5th ed.). St. Louis: Saunders OH: Author. Elsevier. World Health Organization. (2009). Medical eligibility Gibbs, R., Karlan, B., Haney, A., & Nygaard, I. (2008). criteria for contraceptive use (4th ed.). Geneva, Swit- Danforth’s obstetrics and gynecology (10th ed.). Phila- zerland: Author. delphia, PA: Lippincott, Williams, & Wilkins. Hackley, B., Kriebs, J., & Rousseau, M. (2007). Primary care of women: A guide for midwives and women’s health providers. Sudbury, MA: Jones and Bartlett. 4 Pregnancy

Patricia Burkhardt

¶ HUMAN REPRODUCTION AND 2. Stages of development FERTILIZATION a. Zygote—a diploid cell with 46 chromosomes that results from the fertilization of UÊ *ÀViÃÃÊvÊ}>iÌ}iiÃÃ the ovum by a spermatozoan 1. Definition—Development of gametes; oogen- b. Blastomeres—mitotic division of the zy- esis or spermatogenesis gote (cleavage) yields daughter cells called 2. Essential concepts blastomeres a. Oogenesis—developmental process by c. Morula—the solid ball of cells formed by which the mature human ovum is formed; 16 or so blastomeres; mulberry-like ball of haploid number of chromosomes cells that enters the uterine cavity 3 days b. Spermatogenesis—formation of mature after fertilization functional spermazoa; haploid number of d. Blastocyst—after the morula reaches chromosomes the uterus, a fluid accumulates between c. Meiosis—a process of two successive cell blastomeres, converting the morula to a divisions, producing cells, egg or sperm, blastocyst; inner cell mass at one pole to that contain half the number of chromo- become embryo; outer cell mass will be somes in somatic cells trophoblast d. Mitosis—type of cell division of somatic e. Embryo—stage in prenatal development cells in which each daughter cell contains between the fertilized ovum and the fetus, the same number of chromosomes as the i.e., between second and eighth weeks parent cell inclusive e. Haploid number of chromosomes f. Fetus—the developing conceptus after the 23—possessing half the diploid or normal embryonic stage number of chromosomes, i.e. 46, found in g. Conceptus—all tissue products of concep- somatic or body cells tion; embryo (fetus), fetal membranes, and placenta UÊ *ÀViÃÃÊvÊviÀÌâ>Ì 1. Definition—union of ovum and spermat- UÊ * ÞÃ}ÞÊvÊ«>Ì>ÌÊvÊÌ iÊL>ÃÌVÞÃÌ ozoan; usually occurs in fallopian tubes 1. Definition—blastocyst adheres to the endome- within minutes or no more than a few hours trial epithelium by gently eroding between the of ovulation; most pregnancies occur when epithelial cells of the surface endometrium; intercourse occurs 2 days before, or on day of invading trophoblasts burrow into the endo- ovulation metrium; the blastocyst becomes encased and covered over by the endometrium

79 80 Chapter 4 Pregnancy

2. Implantation occurs 6–7 days after fertilization hormones diverse, in greater amounts than and usually in the upper, posterior wall of the any endocrine tissue in all of mammalian uterus physiology 3. Provides physiologic exchange between the a. Steroid hormones maternal and embryonic environment prior to (1) Estradiol-17B full placental function (2) Estriol (3) Progesterone Â Development of the Placenta, (4) Aldosterone Membranes, and Amniotic (5) Deoxycorticosterone Fluid (6) Cortisol b. Protein and peptide hormones • Essential concepts (1) Placental lactogen (hPL) 1. Chorion—an extra-embryonic membrane (2) Chorionic gonadatropin (hCG) that, in early development, forms the outer (3) Chorionic adrenocorticotropin wall of the blastocyst; from it develop the cho- (ACTH) rionic villi, which establish an intimate con- (4) Pro-opiomelanocortin nection with the endometrium, giving rise to (5) Chorionic thyrotropin the placenta (6) Growth hormone variant 2. Chorion frondosum—the outer surface of the (7) Parathyroid hormone-related protein chorion whose villi contact the decidua basa- (PTH-rP) lis; the placental portion of the chorion (8) Calcitonin 3. Chorion laeve—the smooth, nonvillous por- (9) Relaxin tion of the chorion c. Hypothalamic-like releasing and inhibit- 4. Syncytiotrophoblast—outer layer of cells cov- ing hormones ering the chorionic villi of the placenta that are (1) Thyrotropin-releasing hormone in contact with the maternal blood or decidua (TRH) 5. Cytotrophoblast—thin inner layer of the tro- (2) Gonadotropin-releasing hormone phoblast composed of cuboidal cell (GnRH) 6. Decidua capsularias—the part of the decidua (3) Corticotropin-releasing hormone that surrounds the chorionic sac (CRH) 7. Decidua basalis—the part of the uterine de- (4) Somatostatin cidua that unites with the chorion to form the (5) Growth hormone-releasing hormone placenta (GHRH) 8. Decidua parientalis (vera)—the endometrium d. Regulation of blood flow in the placenta; during pregnancy except at the site of the im- maternal blood traverses the placenta planted blastocyst randomly without preformed channels 9. Amnion—the innermost fetal membrane; a and enters the intervillous spaces in spurts thin, transparent sac that holds the fetus sus- propelled by the maternal arterial pressure pended in the liquor amnii or amniotic fluid; it e. The placental “barrier”—the placenta grows rapidly at the expense of the extra- does not maintain absolute integrity be- embyrionic coelom, and by the end of the tween maternal and fetal circulations as third month it fuses with the chorion, forming indicated by the presence of fetal blood the amniochorionic sac, commonly called the cells found in maternal circulation and the bag of waters development of erythroblastosis fetalis

• Placenta—serves as fetal lungs, liver, and kidneys • Umbilical cord until birth while growing and maintaining the con- 1. Anatomy ceptus in a balanced, healthful environment a. Vessels—two arteries that carry fetal deox- 1. Anatomy ygenated blood to the placenta; smaller in a. Trophoblasts diameter than the vein, and one vein car- b. Chorionic villi rying oxygenated blood from the placenta c. Intervillous spaces to the fetus characterized by twisting or d. Chorion spiraling to minimize snarling e. Amnion b. Measurements—0.8–2 cm in diameter; av- f. Decidual plate erage length of 55 cm with range of 30–100 2. Steroid and protein hormones—human tro- cm phoblasts produce more steroid and protein Embryonic and Fetal Development 81

c. Wharton’s jelly—extracellular matrix con- (2) Indomethacin—impairs production of sisting of specialized connective tissue lung liquid, increases fluid movement 2. Abnormalities of length—positively influenced through fetal membranes or decreases by amniotic fluid volume and fetal mobility fetal urine production a. Extremely short cord—associated with 4. Oligohydramnios—volume of amniotic fluid abruptio placentae or uterine inversion; much less than normal the latter is rare a. Conditions associated with b. Abnormally long cord—associated with oligohydramnios vascular occlusion by thrombi and true (1) Fetal—almost always present with knots fetal urinary tract obstruction or renal agenesis • Amniotic fluid (a) Chromosomal abnormalities 1. Production—produced by amniotic epithe- (b) Congenital anomalies lium; water transfers across amnion and (c) Growth restriction through fetal skin; in second trimester fetus (d) Demise starts to swallow, urinate and inspire amniotic (e) Postterm pregnancy fluid (f) Ruptured membranes 2. Volume maintenance—fetal swallowing seems (2) Placental to be a critical mechanism since polyhy- (a) Abruption dramnios is consistently present when fetal (b) Twin-twin transfusion swallowing is inhibited, but other factors con- (3) Maternal tribute to volume balance (a) Uteroplacental insufficiency 3. Polyhydramnios—amniotic fluid index (AFI) (b) Hypertension greater than 24–25 cm (c) Preeclampsia a. Incidence—about 1% of all pregnancies (d) Diabetes b. Significance—two thirds are idiopathic; (4) Drugs one third associated with fetal anomalies, (a) Prostaglandin synthesis inhibitors maternal diabetes, or multiple gestation (b) Angiotensin-converting enzyme c. Etiology—central nervous system or gas- inhibitors trointestinal tract fetal anomalies, e.g., (c) Idiopathic anencephaly, esophageal atresia b. Prognosis d. Signs and symptoms—uterine size far (1) Early onset has poor outcome and beyond expected for gestational age (GA), risk of pulmonary hyperplasia greatly difficulty auscultating fetal heart rate increased (FHR) and palpating fetal parts, mechani- (2) Late pregnancy onset leads to more cal pressure exerted by the large uterus, Cesarean sections for fetal distress i.e., dyspnea, edema, heartburn, nausea c. Management—amnioinfusion is used e. Diagnosis most often in labor to prevent umbilical (1) Physical findings—uterine enlarge- cord compression ment associated with difficulty feeling fetal parts and auscultating fetal Â Embryonic and Fetal heartbeat Development (2) Ultrasonography (USG) differenti- ates from ascites or large ovarian cyst; • Embryonic development—from the beginning of may also identify an associated fetal third week after fertilization to the end of the sev- anomaly enth week f. Pregnancy outcome—the greater the 1. Fourth week—partitioning of heart begins; polyhydramnios, the higher the perinatal arm and leg buds form; amnion begins to un- mortality; preterm labor increases; also sheathe the body stalk that becomes the um- associated with erythroblastosis bilical cord g. Management—treat only if symptomatic 2. Sixth week—head is much larger than body; (1) Amniocentesis—to relieve maternal heart is completely formed; fingers and toes distress; will enable testing of fetal present lung maturity and chromosome 3. All major organ systems are formed except for studies lungs 82 Chapter 4 Pregnancy

• Fetal development: Begins 8 weeks after fertiliza- (2) Sonographic evidence of pregnancy tion; 10 weeks after onset of LMP (3) Palpation of fetal movement 1. 12 weeks—uterus palpable at the symphysis; 2. Differential diagnosis fetus begins to make spontaneous movements a. Pregnancy 2. 16 weeks—experienced observers can deter- b. Leiomyoma mine gender on ultrasound c. Ovarian cyst 3. 20 weeks—weighs 300 g; weight now begins to d. Pseudocyesis increase in a linear manner 4. 24 weeks—weighs 630 g; fat deposition begins; • Dating of pregnancy—determining estimated date terminal sacs in the lungs still not completely of confinement or delivery or birth (EDC or EDD or formed EDB) 5. 28 weeks—weighs 1100 g; papillary membrane 1. Average duration of human pregnancy—280 has just disappeared from the eyes; has 90% days, 10 lunar months, 9 calendar months chance of survival if otherwise normal 2. Methods to determine EDC, EDD, EDB 6. 32–36 weeks—continues to increase weight as a. Naegele’s rule—subtract 3 months, add 7 more subcutaneous fat accumulates days to the first day of the last menstrual period (LMP) then add 1 year or add 9 Â Diagnosis and Dating of months and 7 days to the first day of the Pregnancy LMP b. Additional information is needed to more • Diagnosis precisely set EDB, which can include: 1. Signs of pregnancy (1) Complete menstrual history a. Presumptive—subjective (what the (2) Contraceptive history woman reports) (3) Sexual history (1) Amenorrhea (4) Physical examination for signs and (2) Nausea and/or vomiting symptoms of pregnancy (3) Urinary frequency, nocturia (5) Quickening (4) Fatigue 3. USG for gestational age determination (5) Breast tenderness, tingling, enlarge- a. Combination of measurements is more ment, and changes in color accurate than any one of the following (6) Vasomotor symptoms (fainting) measurements: (7) Skin changes (1) Crown rump length (CRL) (8) Congestion of vaginal mucus (2) Biparietal diameter (9) Maternal belief that she is pregnant (3) Head circumference b. Presumptive—objective (physical (4) Abdominal circumference examination) (5) Femur length (1) Continuation of elevated basal body b. Accuracy by trimester temperature (1) First trimester—CRL is accurate to 3–5 (2) Chadwick’s sign days (3) Appearance of Montgomery’s tuber- (2) Second trimester—Biparietal diam- cles or follicles eter and femur length are most accu- (4) Expression of colostrum rate to within 7–10 days (5) Breast changes (3) Third trimester—after 26 weeks all c. Probable measurements are less accurate; vari- (1) Enlargement of the abdomen ation in biparietal diameter and femur (2) Enlargement of the uterus length is 14–21 days (3) Palpation of the fetal outline (4) Ballottement Â Maternal Physiologic (5) Change in the shape of the uterus Adaptations to Pregnancy (6) Piskacek’s sign (7) Hegar’s sign • Effects of pregnancy on the organs of reproduction (8) Goodell’s sign and implications for clinical practice (9) Palpation of Braxton Hicks 1. Uterus contractions a. Nonpregnant uterus is about 70 g with a (10) Positive pregnancy test 10 mL cavity d. Positive b. First trimester—at 6 weeks the uterus is (1) Fetal heart tones soft, globular, and asymmetric (Piskacek’s Maternal Physiologic Adaptations to Pregnancy 83

sign); at 12 weeks it is 8–10 cm and is ris- (2) 32.5% of white women and 15.7% of ing out of the pelvis nonwhite women c. Early second trimester—at 14 weeks the (3) Heavy heart-shaped pelvis leads to in- uterus is one quarter of the way to um- creased posterior positions, dystocia, bilicus; at 16 weeks it is half way to the operative births umbilicus; 20 weeks the fundus is approxi- c. Gynecoid mately at the umbilicus (1) Commonly known as the “female” d. After 20 weeks, number of centimeters pelvis with tape measure equals number of (2) 41–42% of women’s pelvis shapes weeks of gestation within 2 cm (3) Good prognosis for vaginal birth e. By term the uterus weighs about 1100 g d. Platypelloid with a 5-liter volume (1) Rare pelvic type 2. Cervix (2) Occurs in less than 3% of women a. Develops increased vascularity (3) Prognosis of vaginal delivery is poor b. Hegar’s sign is softening of the isthmus secondary to short AP diameter c. Chadwick’s sign is bluish color of the cervix • Effect of pregnancy on major body systems, with d. Goodell’s sign is softening of the cervix related clinical implications and patient education e. A thick mucous plug forms secondary to needs glandular proliferation 1. Gastrointestinal 3. Ovaries—corpus luteum a. Mouth and pharynx a. Anovulation secondary to hormonal inter- (1) Gingivitis is common and may result ruption of the feedback loop in bleeding of gums b. Corpus luteum persists under the influ- (2) Increased salivation ence of the hormone hCG until about 12 (3) Epulis (a focal swelling of gums) may weeks develop and resolves after the birth c. Corpus luteum is responsible for the se- (4) Pregnancy does not increase tooth cretion of progesterone to maintain the decay endometrium and pregnancy until the b. Esophagus placenta takes over production (1) Decreased lower esophageal sphincter d. Ovaries also thought responsible for pro- pressure and tone duction of relaxin (2) Widening of hiatus with decreased 4. Vagina tone a. Chadwick’s sign—bluish color (3) Heartburn is common b. Thickening of vaginal mucosa c. Stomach c. Increase in vaginal secretions (1) Decreased gastric emptying time d. Some loosening of connective tissue in (2) Incompetence of pyloric sphincter preparation for birth (3) Decreased gastric acidity and hista- 5. Breasts mine output a. Increase in size secondary to mammary d. Large and small intestines hyperplasia (1) Decreased tone and motility b. Areola becomes more deeply pigmented (2) Altered enzymatic transport across and increased in size villi resulting in increased absorption c. Colostrum may be expressed after the first of vitamins several months (3) Displacement of intestines, cecum, d. Montgomery’s follicles and appendix by the enlarging uterus e. Vascularity increases e. Gallbladder 6. Pelvis—four pelvic types (1) Decreased tone a. Anthropoid (2) Decreased motility (1) 23.5% of white women and 50% of f. Liver nonwhite women (1) Altered production of liver enzymes (2) Shape favors a posterior position of (2) Altered production of plasma proteins the fetus and serum lipids (3) Adequate for a vaginal birth due to 2. Genitourinary/renal large size a. Dilation of renal calyces, pelvis, and ure- b. Android ters resulting in increased risk of urinary (1) Commonly known as a “male” pelvis tract infection 84 Chapter 4 Pregnancy

b. Decreased bladder tone e. May have exaggerated splitting of S1, audi- c. Renal blood flow increases 35–60% ble third sound, or soft transient diastolic d. Decreased renal threshold for glucose, murmur protein, water soluble vitamins, calcium, f. Cardiac output is increased and hydrogen ions g. Diastolic blood pressure is lower in first e. Glomerular filtration rate increases two trimesters due to development of new 40–50% vascular beds and relaxation of peripheral f. All components of the renal-angiotensin- tone by progesterone that results in de- aldosterone system increase, resulting in creased flow resistance retention of sodium and water, resistance 7. Integumentary system of pressor effect of angiotensin II, and a. Vascular changes maintenance of normal blood pressure (1) Palmar erythema 3. Musculoskeletal (2) Spider angiomas a. Relaxin and progesterone affect cartilage (3) Varicose veins and hemorrhoids and connective tissue (4) Hyperpigmentation is believed to be (1) Results in a loosening of the sacroiliac related to estrogens and progesterone joint and symphysis pubis which have a melanocyte-stimulating (2) Encourages the development of the effect characteristic gait of pregnancy (5) Chloasma, freckles, nevi, and recent b. Lordosis scars may darken 4. Respiratory (6) Linea nigra a. Level of diaphragm rises about 4 cm be- (7) Increase in sweat/sebaceous activity cause of the increase in uterine size (8) Change in connective tissues resulting b. Thoracic circumference increases by 5–6 in striae gravidarum cm and residual volume is decreased b. Hair growth c. A mild respiratory alkalosis occurs due to (1) Estrogen increases the length of the

decreased PCO2 anagen (growth) phase of the hair d. Congestion of nasal tissues occurs follicles e. Respiratory rate changes very little, but the (2) Mild hirsutism may develop in early tidal volume, minute ventilatory, and min- pregnancy ute oxygen uptake all appreciably increase 8. Endocrine f. Some women experience a physiologic a. Pituitary dyspnea, due to the increased tidal vol- (1) Prolactin levels are 10 times higher at

ume and lower PCO2 term than in the nonpregnant state 5. Hematologic changes (2) Enlarges by over 100% a. Blood volume increases 30–50% from non- b. Thyroid pregnant levels (1) Increases in size (about 13%) b. Plasma volume expands which results in a (2) Normal pregnant woman is euthyroid physiologic anemia due to estrogen-induced increase in c. Hemoglobin averages 12.5 g/dL thyroxin binding globulin (TBG) d. Some require an additional gram of iron (3) Thyroid-stimulating hormone (TSH) during pregnancy does not cross the placenta e. Pregnancy can be considered a hyperco- (4) Thyroid stimulating immunoglobulins agulable state, since fibrinogen (Factor and Thyrotropin-releasing hormone I), and Factors VII–X all increase during (TRH) cross the placenta pregnancy c. Adrenal glands 6. Cardiovascular system (1) Remain the same size, however, there a. Cardiac volume increases by about 10% is an increase in the zona fasciculata and peaks at about 20 weeks that produces glucocorticoid b. Resting pulse increases by 10–15 beats per (2) Twofold increase in serum cortisol minute with the peak at 28 weeks d. Pancreas c. Slight cardiac shift (up and to the left) due (1) Hypertrophy and hyperplasia of the B to the enlarging uterus cells d. 90% of pregnant women develop a physi- (2) Insulin resistance as a result of the ologic systolic heart murmur placental hormones especially hPL Maternal Psychological/Social Changes in Pregnancy 85

9. Metabolism b. Personal hygiene, brassieres, vaginal dis- a. Weight gain during pregnancy charge, etc. (1) Recommended weight gain is 11–40 c. Infant feeding—breast and/or bottle lb depending on prepregnancy body d. Avoidance and alleviation of—backache, mass index (BMI) constipation, hemorrhoids, leg aches, var- (2) Average weight gain is 28 lbs—1.5 icosities, edema and round ligament pain lb for placenta, 2 lb for amniotic e. Nutritional needs, diet and weight gain. fluid, 2.5 lb for uterine growth, 3 lb f. Discuss/review danger signs and for increased blood volume, 1 lb for symptoms increased breast tissue, 7.5 lb for the fetus and the remainder for maternal • Third trimester fat deposits 1. First part (27–36 weeks)—concerned with (3) Protein metabolism is increased baby’s needs (4) Fat deposit and storage is increased to a. Psychological responses prepare for breastfeeding (1) Introversion (5) Carbohydrate metabolism is altered, (2) Period of watchful waiting the blood glucose levels are 10–20% b. Prenatal anticipatory guidance lower than prepregnant states (1) Fetal growth and well-being (2) Review hygiene, clothing, body me- Â Maternal Psychological/ chanics and posture, positions of Social Changes in Pregnancy comfort (3) Physical and emotional changes • Pregnancy is a time of many transitions, a woman (4) Sexual needs/intercourse is vulnerable, and maternal moods are labile (5) Alleviation of backache, Braxton Hicks contractions, dyspnea, round liga- • First trimester (1–13 weeks)——focus on physical ment pain, leg aches or edema changes and feelings (6) Confirm infant feeding plans and dis- 1. Psychological responses cuss preparation for breastfeeding a. Ambivalence (7) Preparation for baby supplies and b. Adjustment help at home 2. Prenatal anticipatory guidance (8) Prenatal classes/approach a. Normal changes of pregnancy; breast full- (9) Involvement of significant other ness, urinary frequency, nausea/vomiting, (10) Review danger signs at each visit and fatigue (11) If planning tubal ligation, prepare pa- b. Calculate and explain EDD and compari- pers if required son with uterine size c. Women anticipate birth and infant care c. Client’s and healthcare provider’s expecta- (1) Discuss fetal movement tions for visits (2) Personal hygiene needs/concerns, al- d. Importance of ongoing care in preg- leviation of discomforts of pregnancy nancy to promote well-being and prevent (3) Discuss recognition of Braxton Hicks problems and prodromal contractions and dif- e. Rationale for vitamins and iron ferentiation from true labor supplements (4) Discuss labor, contractions, and labor f. Resources available for education, emer- progress and expectations of labor gency care, etc. (5) Breathing and relaxation techniques; g. Discuss/review danger signs and labor support options symptoms (6) Provisions for needs of other children, sibling issues, and care of children • Second trimester (14–26 weeks)—more aware of during hospital stay the fetus as a person (7) Review signs of labor 1. Psychological responses (8) Continue discussion of relaxation and a. Acceptance breathing techniques; latent labor b. Period of radiant health coping skills 2. Prenatal anticipatory guidance (9) Final home preparations a. Fetal growth, movement and fetal heart (10) Discuss procedures particular to tones (FHT) home/birthing center (BC), hospital— analgesia, IVs, examinations, labor 86 Chapter 4 Pregnancy

care, birthing plans, postpartum care, 7. Stillbirth rate (fetal death rate)—number of and supplies needed stillborn infants per 1000 infants born, includ- (11) Confirm plans for transport to the ing live births and stillbirths hospital, who to call, and where to 8. Neonatal death—early neonatal death is death go; hospitalization and process of during the first 7 days after birth; late neonatal admission death is death between 7 and 28 days (12) Consider birth control/family plan- 9. Neonatal mortality rate—number of neonatal ning needs deaths/1000 live births (13) Discuss emergency arrangements 10. Perinatal mortality rate—number of stillbirths in the event of danger signs, prema- plus neonatal deaths per total births ture rupture of membranes (PROM), 11. Infant mortality rate—number of infant deaths bleeding, severe headache, pain, etc. (first 12 months of life) per 1000 live births 12. Maternal morbidity—illness or disease associ- • Risk factors for psychological well-being ated with childbearing 1. Limited support network 13. Maternal mortality ratio—number of maternal 2. High levels of stress deaths that result from the reproductive 3. Psych/mental health issues process/100,000 live births 4. Problem pregnancies 14. Abortus—fetus or embryo removed or expelled from the uterus during the first half of gestation Â Overview of Antepartum Care (20 weeks or less), weighing less than 500 g 15. Preterm infant—infant born before 37 com- • Purpose and objectives of antepartum care—to pleted weeks (259th day) differentiate normal and pathologic maternal-fetal 16. Term infant—infant born after 37 completed alterations throughout pregnancy by employing weeks of gestation up until 42 completed maternal-fetal assessment methods, techniques, weeks of gestations (260–294 days) and parameters appropriate to the antepartum 17. Postterm infant—infant born anytime after period, specifically: completion of the 42nd week beginning with 1. Application of the management process in- day 295 cluding components of history and physical 18. Direct maternal death—death of the mother examination at initial and interval visits resulting from obstetrical complications of 2. Critical evaluation of indications and tech- pregnancy, labor, or the puerperium; and from niques for the application of therapeutics dur- interventions, omissions, incorrect treatment, ing the antepartum period or a chain of events resulting from any of these 3. Incorporation of current evidence and re- factors search in the care of women and families during the antepartum period Â Antepartum Visit

• Definition of the essential concepts (National Cen- • Terminology that describes women and their preg- ter for Health Statistics and the Centers for Disease nancies (Varney, Kriebs, & Gegor, 2004) Control and Prevention, 2003) 1. Gravida—the number of times a woman has 1. Fertility rate—number of live births/1000 fe- been pregnant males 15–44 years of age 2. Para—refers to the number of pregnancies that 2. Birth rate—number of live births per 1000 terminated in the birth of a fetus or fetuses population that reached the point of viability, i.e., 500 g or 3. Live birth—infant at, or sometime after birth 20 weeks’ gestation breathes spontaneously, or shows any other 3. Nulligravida—a woman who has never been sign of life pregnant 4. Stillbirth (fetal death)—no signs of life are 4. Nullipara—a woman in her first pregnancy present at or after birth or who has not carried a baby to 500 g or 20 5. Neonatal period—28 completed days after weeks birth 5. Primigravida—a woman who is pregnant for 6. Perinatal period—all births weighing 500 g or the first time more and ending at 28 completed days after 6. Primipara—a woman who had one pregnancy birth; when perinatal rates are based on gesta- that ended with a birth in which the fetus tional age, this is defined as 20 weeks or longer reached the age of viability 7. Multigravida—a woman pregnant two or more times Antepartum Visit 87

8. Multipara—has carried two or more pregnan- d. The pelvis—(only the true pelvis is of cies to viability significance) true pelvis is bony canal 9. Grand multipara—has given birth seven times through which the fetus passes that lies or more below the pelvic brim (linea terminalis) 10. TPAL numerical description of parity—four- (1) Three planes of obstetric signifi- digit system that counts all fetuses/babies cance—inlet, midplane, and outlet born rather than pregnancies carried to viabil- (2) Critical diameters for evaluation of ity: T = term babies ($ 37 wks or 2500 g), P = pelvic adequacy premature babies (20–36 wks; 500–2499 g), A = (a) Inlet—AP, transverse Abortions (any fetus born < 20 wks and 500 g), (b) Midplane—AP, transverse, poste- L = living children currently rior sagittal (c) Outlet—AP, transverse, posterior • Components of the antepartum visit (initial and sagittal return) (3) Assessing and measuring the pelvis— 1. The Pregnant Patient’s Bill of Rights clinical pelvimetry 2. Complete history (a) Diagonal conjugate—extends a. Menstrual history from middle of sacral promontory b. Contraceptive history to middle of lower margin of sym- c. Obstetric history including quickening physis pubis; only AP diameter d. Medical/Surgical history that can be measured clinically; e. Sexual history should be more than 11.5 cm f. History or current physical, sexual, emo- (b) Pubic arch—formed by the de- tional abuse scending rami of pubic bones g. Medicines and/or nonallopathic healing and inferior margin of symphysis practices pubis; angle should be at least 90 h. Family history degrees i. Genetic risk (c) Interspinous diameter—distance j. Health habits between the ischial spines, nor- k. Environmental exposures mally measures 10 cm, is smallest l. Social history diameter of the pelvis and defines m. Exercise and nutrition history the midplane n. Immunizations (d) Ischial spines—may be promi- 3. Physical examination nent, encroaching or blunt; assess a. Height, weight, and vital signs the sidewalls and the sacrum; best b. Complete physical examination if blunt c. Abdominal examination (e) Sacrosciatic notch—note shape (1) Fundal height—growth by weeks of and width in fingerbreadths gestation (f) Side walls—side walls extend (2) Leopold’s maneuvers—four ab- from the upper anterior angle dominal palpation maneuvers used of the sacrosciatic notch to the to determine the following fetal ischial tuberosities and are as- characteristics: sessed as straight, convergent, or (a) Lie divergent; should be straight (b) Presentation (g) Sacrum—assess the inclination (c) Position of the sacrum, the length, and the (d) Attitude curvature; curved is best (e) Variety (h) Intertuberous diameter—distance (f) Estimated fetal weight between the ischial tuberosities, (4) Fetal heart tones—dating pregnancy about 11 cm and assessing fetal position; different 4. Laboratory studies used in the provision of an- timing using fetoscope or doptone tepartum care (5) Bimanual examination a. Initial visit (6) Uterine sizing—first trimester to de- (1) Blood type, Rh factor, antibody screen, termine gestational age CBC or hematocrit, RPR or VDRL, ru- (7) Clinical pelvimetry—measurement bella titer, hepatitis B surface antigen

of the features of the bony pelvis with (HBsAg), urine culture/screen the examiner’s hand 88 Chapter 4 Pregnancy

(2) HIV testing should be recommended d. Some prefer biweekly visits 41 weeks to to all pregnant women with option to delivery decline testing e. Schedule more frequent visits as appro- (3) Gonorrhea, chlamydia, and wet prep priate; some providers recommend fewer tests as indicated by history and phys- prenatal visits if there are no problems ical examination findings 6. Content of prenatal revisits (4) Pap test per routine recommendations a. History (5) PPD, Hgb electrophoresis, genetic b. Physical examination—blood pressure, screening tests as indicated by history urine dipstick, weight, FHT, fundal height and risk factors c. Anticipatory management b. Multiple marker screen—triple screen d. Anticipatory guidance (maternal serum alphafetoprotein e. Health education and counseling [MSAFP], estriol and hCG) or quad screen f. Appropriate screening (MSAFP, estriol, hCG and inhibin A) at 15– 22 weeks’ gestation (optimal 16–18 weeks) • Prenatal risk factors c. Ultrasound—may perform at approxi- 1. History mately 18–20 weeks for gestational age a. Genetic factors and fetal structural evaluation (1) Maternal age at or older than 35 d. Gestational diabetes screening (2) Previous child with a chromosome at 24–28 weeks—see section this abnormality chapter on Selected Obstetrical (3) Family history of birth defects or men- Complications—Diabetes tal retardation e. Repeat antibody screen at 26–28 weeks for (4) Ethnic/racial origins Rh-negative mother (a) African—sickle cell disease f. Repeat CBC/Hct, VDRL/RPR, Chlamydia, (b) Mediterranean or East Asian—B GC, HIV, HBsAg as indicated by history, thalassemia physical examination findings, and risk (c) Jewish—Tay-Sachs disease factors in third trimester b. Multiple pregnancy losses/previous g. Group B streptococcus (GBS) screening at stillbirth 35–37 weeks—vaginal introitus and rectal c. Psychological/mental health disorders specimens d. History of IUGR h. Some other laboratory studies that might e. Preterm birth(s) be indicated include: 2. Current pregnancy (1) Amniocentesis or chorionic villus a. Abnormal multiple marker screening sampling(CVS) b. Exposure to possible teratogens (2) Tay-Sachs screening (1) Radiation (3) Maternal/paternal chromosomal (2) Alcohol/medications/other studies substances (4) Chest radiographs (3) Occupational exposures (5) Blood chemistry (SMA 6 & 12, or (4) Infections Chem 7 & 20) (a) Toxoplasmosis (6) Thyroid studies (b) Rubella (7) Toxoplasmosis testing (c) CMV (8) Cytomegalovirus (CMV) (d) Syphilis (9) HSV cultures or antibody testing c. Intrauterine Growth Retardation (IUGR) (10) ANA d. Oligohydramnios/polyhydramnios (11) Antiphospholipid antibodies e. Diabetes (12) Serum iron studies (1) Pregestational (13) Blood glucose studies (3-hour GTT, (2) Gestational FBS, 2-hour postprandial, and hemo- (3) Insulin dependent globin A1c) f. Hypertension 5. Subsequent (interval) prenatal visits—fre- (1) Chronic quency of (2) Gestational a. Every 4 weeks to 28 or 32 weeks g. Preeclampsia/eclampsia b. From 28 or 32 weeks to 36 weeks every 2 h. Multiple gestation weeks i. PROM c. Weekly visits from 36 weeks to 41 weeks j. Post dates Common Discomforts of Pregnancy and Comfort Measures 89

k. Decreased fetal movement 3. Decrease activities and plan rest periods l. Rh isoimmunization 4. Decrease fluid intake in evening to decrease nocturia Â Common Discomforts of Pregnancy and Comfort • Heartburn Measures 1. Small frequent meals 2. Decrease amount of fluids taken with meals; • Nausea and vomiting of pregnancy (most common drink fluids between meals in first trimester) 3. Papaya (may recommend fresh, dried, juice, or 1. Small frequent meals, no restriction on the enzymes) kind of food nor how often 4. Elevate head of bed 10–30 degrees 2. Discontinue prenatal vitamins with iron until 5. Slippery Elm Bark throat lozenges nausea and vomiting resolved; continue folic 6. Antacids

acid 7. Proton pump inhibitors and H2 blockers— 3. Raspberry tea or peppermint tea, carbonated Pregnancy Category B beverages, hard candy 4. Acupressure, including sea bands for wrists • Constipation 5. Ginger 1 g per day in divided doses 1. Increased fluids, fiber

6. Pyridoxine (Vitamin B6) 25 mg bid or tid orally 2. Prune juice or warm beverage in the morning 7. Doxylamine 12.5 mg bid or qid with pyridoxine 3. Encourage exercise orally 4. Stool softeners 8. Metoclopramide 5 to 10 mg g q6–8h orally 9. Promethazine 25 mg q4h per rectal • Hemorrhoids suppository 1. Avoid constipation or straining with a bowel movement • Breast tenderness 2. Elevate hips with pillow or knee–chest position 1. Good support brassiere 3. Sitz baths 2. Careful lovemaking 4. Witch hazel or epsom salt compresses 3. Reassurance that it will soon pass 5. Reinsert hemorrhoid with lubricated finger 6. Kegel exercises • Backache 7. Topical anesthetics; Pregnancy Category C if 1. Consider musculoskeletal strain, sciatica, sac- combined with steroid roiliac joint problem, preterm labor, urinary tract infection • Varicosities 2. Nonpathologic—related to normal changes in 1. Support stockings; apply before getting out of pregnancy bed a. Massage 2. Avoid wearing restrictive clothing b. Application of ice or heat 3. Perineal pad if vaginal varicosities c. Hydrotherapy 4. Rest periods with legs elevated; avoid crossing d. Pelvic rock legs e. Good body mechanics f. Pillow in lumbar area when sitting, or be- • Leg cramps tween legs when lying on side 1. Decrease phosphate in diet; no more than two g. Pregnancy support harness or girdle glasses of milk per day h. Good support brassiere 2. Massage affected leg i. Supportive low-heeled shoes 3. Don’t point toes, flex ankle to stretch calf 3. Sacroiliac joint problems 4. Keep legs warm a. Teach appropriate exercises 5. Walk, exercise b. Nonelastic sacroiliac belt 6. Calcium tablets c. Trochanteric belt worn below the abdo- 7. Magnesium tablets men at the femoral heads to increase joint stability • Presyncopal episodes 1. Change positions slowly • Fatigue 2. Push fluids; regular caloric/glucose intake 1. Reassurance that this is a normal first trimes- 3. Avoid lying flat on back; avoid prolonged ter problem and will pass standing or sitting 2. Mild exercise and good nutrition 90 Chapter 4 Pregnancy

• Headaches 5. Mild analgesic such as acetaminophen 325 mg 1. Head, shoulder, and/or neck massage 1–3 tabs every 4 hours as needed 2. Acupressure 3. Hot or cold compresses Â Nutrition During Pregnancy 4. Rest 5. Warm baths • Recommended daily allowances 6. Meditation and biofeedback 1. Calories—2,500 kcal 7. Aromatherapy 2. Protein—average of 60 g/day throughout 8. Mild analgesic such as acetaminophen 325 mg pregnancy 1–3 tablets every 4 hours as needed • Weight gain in pregnancy • Leukorrhea 1. Body mass index (BMI) (weight/height2)—only 1. Rule out vaginitis and STDs anthropometric measurements with docu- 2. Good perineal hygiene mented clinical value for assessment of gesta- 3. Wear cotton crotch panties; change panties as tional weight gain often as necessary 2. Weight-for-height categories 4. Unscented pantiliners a. Underweight—BMI less than18.5 5. Instructions to avoid douching and use of b. Normal weight—BMI 18.5–24.9 feminine sprays c. Overweight—BMI 25.0–29.9 d. Obese—BMI 30.0 or higher • Urinary frequency 3. Determinants of gestational weight gain 1. Decrease fluids in evening to avoid nocturia a. Prepregnant weight—if overweight at 2. Avoid caffeine conception more likely to gain less weight 3. Rule out urinary tract infection than normal-weight woman b. Low gestational weight gain associated • Insomnia with 1. Warm bath (1) Low family income 2. Hot drink—warm milk, chamomile tea (2) Black race 3. Quiet, relaxing, minimally stimulating (3) Young age activities (4) Unmarried status 4. Avoid daytime napping (5) Low educational level c. Multiple gestation • Round ligament pain d. Developing pathology—toxemia 1. Rule out other causes of abdominal pain, such 4. Consequences of gestational weight gain as appendicitis, ovarian cyst, placental separa- a. Low gestational weight gain is associated tion, inguinal hernia with 2. Warm compresses, ice compresses (1) Growth-restricted infants 3. Hydrotherapy (2) Fetal and infant mortality 4. Avoid sudden movement or twisting b. High gestational weight gain is associated movements with 5. Flex knees to abdomen, pelvic tilt (1) Greater rate of large infant weight, 6. Support uterus with a pillow when lying down which leads to 7. Maternity abdominal support or girdle (a) Fetopelvic disproportion (b) Operative delivery (forceps, vac- • Skin rash uum, or Cesarean) 1. Ice (c) Birth trauma 2. Aveeno bath (d) Asphyxia 3. Diphenhydramine—25 mg orally every 4 hours (e) Mortality as needed for itching (2) Above associations are more pro- 4. Dermatology referral as needed nounced in short women (< 157 cm or 62 in) • Carpal tunnel syndrome (tingling and numbness 5. Recommended patterns and quantity of of fingers) weight gain 1. Good posture a. Normal prepregnant weight—0.8–1.0 lb 2. Lying down per week during second and third trimes- 3. Rest and elevate affected hands ters for total of 25–35 lb 4. Ice, wrist splints The Woman and Her Family and Their Role in Pregnancy 91

b. Underweight before pregnancy—1.0–1.3 • Pregnancy as essential, permanent family and life lb per week in second and third trimesters change for total of 28–40 lb 1. The significance of change in relation to c. Overweight before pregnancy—0.5–0.7 lb pregnancy per week in second and third trimesters 2. Role adaptation needed to successfully cope for total of 15–25 lb with pregnancy d. Obese before pregnancy—0.4–0.6 lb per 3. Family resources to be mobilized to enable the week in second and third trimesters for family to cope total of 11–20 lb a. Clear and continuous communication of information • Diet history—recall of fluid and solid food intake b. Decision making by the woman and fam- in the last 24 hours, whose purpose is to evaluate ily as indicated adequacy of nutrition and formulate a plan for nu- c. Family’s development of an appropriate trition counseling birth plan 1. Components of diet history (1) Childbirth preparation a. Qualitative components of the intake (2) Breast feeding b. Quantitative, but only if weight is an issue (3) Child-rearing classes c. Ascertain how typical the last 24-hour in- d. Information regarding critical resources in take was to usual intake birth site 2. Components of diet counseling (1) Labor and birth procedures and a. Diet assessment expectations b. Set a weight gain goal with the woman for (2) Rooming-in the pregnancy (3) Breastfeeding support c. Discuss food preferences and relationship (4) Sibling visitation and/or presence at to goal birth d. Review generally or specifically at each (5) Family visitation visit, depending on results (6) Possibility of early discharge e. Include fetal growth as part of parameters 3. Cultural and personal beliefs about nutrition • Perinatal loss and associated grief stages and that may modify a diet plan include: process a. Pica—ingestion of nonfood substances, 1. Factors associated with the concept of loss and i.e., starch, clay grieving b. Vegetarianism a. Perception of the individual(s) experienc- c. Hot and cold foods and when they can be ing the loss of its severity eaten b. Support and assistance in doing grief work d. Discern eating patterns and beliefs perti- 2. Types of maternity losses nent to pregnancy in the woman’s culture a. Infertility b. Loss of a baby Â The Woman and Her Family (1) Miscarriage and Their Role in Pregnancy (2) Abortion (3) Stillbirth • Family (4) Adoption 1. Assessment of family size, structure and c. Loss of expectations relationships (1) Premature infant 2. Significant individuals involved in pregnancy (2) Congenital deformities 3. Family roles and their relationship to family (3) “Damaged” infant function (4) Exclusive wife/husband relationship a. Occupations 3. Stages of grief b. Income levels a. Shock, manifested by c. Education levels (1) Denial d. Nationality and ethnic background (2) Disbelief e. Relationship status and intensity (3) Fear 4. Feelings and thoughts about this pregnancy (4) Isolation and any past pregnancies and births (5) Crying (6) Hostility (7) Bitterness 92 Chapter 4 Pregnancy

(8) Introversion • Principles of teaching for role of parent educator (9) Sadness 1. Individual teaching and counseling—topic (10) Numbness and quantity of information need to fit the b. Physical signs and symptoms client (1) Weight loss 2. Prioritize information provision (2) Insomnia a. Respond to questions or experiences of (3) Fatigue the woman (4) Restlessness b. Anticipatory guidance of pregnancy (5) Shortness of breath realities (6) Chest pain c. Danger signs of critical complications; c. Suffering—the reality stage drug dangers, both OTC and illegal drugs; (1) Acceptance of the reality and any other information needed for (2) Adaptation health and well-being of woman and fetus (3) Preoccupation with lost person (4) Questioning of what happened and • Childbirth education why 1. Preparation for childbearing—ultimately aids (5) Feelings of fear, guilt, and anger in reducing need for analgesics/anesthetics persist during labor d. Resolution—acceptance and adaptation is a. Formal or informal complete b. Content to be included: (1) Reinvests in other significant (1) Bodily changes in pregnancy with as- relationships sociated reproduction anatomy (2) Moves on but remembers lost person (2) Exercises for ADL during pregnancy 4. Maladaptive grief reactions and for labor a. Avoidance or distortion of normal grief (3) Nutrition expression (4) Fetal growth and development b. Agitated depression; psychosomatic (5) Substance abuse conditions (6) Signs of beginning labor c. Morbid attachment to possessions of (7) Information for infant feeding deci- deceased sion making d. Persistent loss of self-esteem (8) Preparation for breastfeeding 5. Healthcare provider’s role in helping the nor- (9) Postpartal course and care mal grieving process (10) Preparation of siblings for birth a. Listen (11) Pain coping strategies in labor b. Facilitate woman’s expression of feelings (12) Vaginal birth after Cesarean (VBAC) c. Provide nonjudgmental environment versus elective repeat Cesarean sec- d. Accept behaviors of grief tion (ERCS) if previous C-section 2. Learning needs of the breastfeeding woman Â Teaching and Counseling a. Anticipatory guidance for woman with inverted nipples • Principles of learning that apply to women/ b. Principles of milk production families during pregnancy (1) Caloric needs of mother 1. Factors that facilitate or impede learning (2) Liquid needs of mother a. Readiness of the learner; time to discuss (3) Mechanics of proper infant position- b. Healthcare provider’s knowledge of wom- ing and latching on an’s and family’s learning needs (4) Factors that affect milk supply c. Group teaching—enhances and enriches 3. Learning needs for parenthood learning a. Plans for the baby’s health care 2. Factors that critically influence teaching/ b. Needs and adaptation for the home learning c. Identification of family/social supports a. Alternative life styles; different cultures b. Disadvantaged social milieus • Family planning c. Age and maturity—adolescents, educa- 1. Pregnancy learning needs for postpartum con- tional level, life experience traceptive options 2. Learning needs when considering postpartum bilateral tubal ligation Techniques Used to Assess Fetal Health 93

a. Expert counseling 3. Category C—Animal studies have shown an b. Signing consent papers adverse effect, and there are no adequate and well-controlled studies in pregnant women. • Human sexuality and pregnancy OR 1. The effects of pregnancy on female and male No animal studies have been conducted, and sexual response there are no adequate and well-controlled 2. Changes in sexual desire throughout preg- studies in pregnant women. nancy—impacted by hormones, energy level, 4. Category D—Studies, adequate well-controlled relationship, body image, fears of hurting baby, or observational, in pregnant women have cultural beliefs and practices demonstrated a risk to the fetus. However, the 3. Concept of body image—may feel awkward, benefits of therapy may outweigh the potential clumsy, ugly, especially in late pregnancy risk. 4. Factors during pregnancy that may alter this 5. Category X—Studies adequate, well-controlled image—support or lack thereof for her feel- or observational, in animals or pregnant ings; responses, either positive or negative, women have demonstrated positive evidence from people of importance of fetal abnormalities. The use of the product 5. Variations in sexual practice and their use dur- is contraindicated in women who are or may ing pregnancy become pregnant (FDA, 2001). a. Positions for intercourse—alternate positions may enhance comfort with increase • Indications and contraindications for the use of in abdominal size vaccinations during pregnancy b. Cunnilingus—avoid blowing into vagina 1. Hepatitis B—high-risk women who are antigen to reduce risk of air embolism and antibody negative can be vaccinated dur- c. Fellatio ing pregnancy d. Anal intercourse 2. Tetanus—vaccination during pregnancy can 6. Sexual activity may be continued throughout a protect at-risk newborns against neonatal healthy pregnancy tetanus; in maternal trauma, may be indicated 7. The potential relationship between orgasm 3. Rubella—(German measles)—attenuated live- and uterine contractions virus vaccine contraindicated immediately a. Contraindicated if preterm labor threatens before or during pregnancy; vaccinate imme- b. May help initiate labor diately after childbirth 4. Varicella—attenuated live-virus vaccine Â Pharmacologic (Varivax) contraindicated in pregnancy Considerations in the 5. Influenza—trivalent inactivated influenza Antepartum Period vaccine (TIV) recommended for all pregnant women during influenza season; live attenu- • Teratogens (derived from Greek word meaning ated nasal influenza vaccine contraindicated “monster”)—any agent that acts during embryonic during pregnancy or fetal development to produce a permanent alteration of form or function Â Techniques Used to Assess Fetal Health • FDA risk factor categories for prescription drugs in pregnancy • Ultrasound (USG, US) 1. Category A—Adequate, well-controlled stud- 1. Definition—method in which intermittent ies in pregnant women have not shown an high-frequency sound waves are transmitted increased risk of fetal abnormalities. through tissues by way of a transducer placed 2. Category B—Animal studies have revealed no on the abdomen or in the vagina which are evidence of harm to the fetus, however, there then reflected off the underlying structures so are no adequate and well-controlled studies in that tissues, fluid, bones, fetal activity, and ves- pregnant women. sel pulsations are discernible OR 2. Types of ultrasound Animal studies have shown an adverse effect, a. Real-time ultrasound is the most com- but adequate and well-controlled studies in monly used method pregnant women have failed to demonstrate a b. Transvaginal ultrasound may be used in risk to the fetus. early pregnancy 3. Some uses for ultrasound in obstetrics a. Assessment of bleeding in the first trimester 94 Chapter 4 Pregnancy

b. R/O suspected ectopic pregnancy or hyda- c. If a lethal anomaly is diagnosed and preg- tidiform mole nancy continues, allows parents/care pro- c. Estimated gestational age for patients with viders to plan, i.e. avoid a C-section uncertain LMP 6. Special precaution—if mother is Rh negative d. Evaluation of size/dates discrepancy and at risk for isoimmunization, administer e. R/O suspected multiple gestations or fetal RhoGAM with amniocentesis anomalies f. Adjunct to special procedures—reproduc- • Chorionic villus sampling (CVS)/Chorionic villus tive endocrinology procedures, CVS, am- biopsy (CVB) niocentesis, fetoscopy 1. A sample of chorionic villi from placenta is g. Sex identification aspirated either transabdominally or transcer- h. Evaluation of second and third trimester vically; outer trophoblastic layer is obtained bleeding because these tissues have same genetic i. Evaluation of pelvic mass or uterine make-up as the fetus; tissue is examined for abnormality genetic information j. Evaluation of placental problems, loca- 2. Used for prenatal diagnosis; performed be- tion, grade tween 10 and 13 weeks k. Evaluation of fetal growth—macrosomia, 3. Benefits intrauterine growth retardation (IUGR), a. Performed 3–4 weeks earlier than AFI amniocentesis l. Biophysical profile—AFI, fetal movements, b. Cultures grow rapidly, resulting in early respiratory movements, fetal tone diagnosis m. Estimation of fetal size and/or 4. Risks presentation a. Infection, bleeding, miscarriage n. Rule out suspected fetal demise b. Risk of limb deformities (if performed before 9 weeks) • Doppler velocimetry blood flow assessment c. Technically more difficult 1. Used in tertiary settings only if utero-placental d. Contraindicated when there is a maternal insufficiency resulting in IUGR is suspected or blood group sensitization is present 2. Detects velocity of blood flow through the fetal • Fetal movement counting/Fetal kick counts—ma- umbilical artery to the placenta and is dis- ternal self-report of fetal movement to assess fetal played in a waveform wellness 3. Normal waveforms produced when the ratio 1. Fetal movement counting (FMC) of systolic to diastolic blood flow (S/D ratio) is a. Most women are aware of fetal movement around 3; abnormal ratio is more than 3 between 16 and 22 weeks’ gestation; multiparas are generally aware of movement • Amniocentesis sooner than nulliparas 1. Amniotic fluid is aspirated from the amniotic b. The fetus has periods of sleep and wake- sac and evaluated for genetic well-being or fulness that change according to gestation disorders, and fetal lung maturity c. Fetal movement is strongest between 29 2. Usually performed between 14 and 16 weeks and 38 weeks for genetic evaluation or assessment of neural d. Fetal movement counting is a safe, simple, tube defects no-cost, noninvasive fetal assessment 3. Used later in pregnancy—assessment of lung technique maturity; R/O amnionitis or fetal hemolytic e. Research has demonstrated that fetal ac- disease (Rh or anti-D) tivity is a good predictor of well-being 4. Risks—infection, bleeding, preterm labor, f. Dramatic decrease or cessation of move- PROM, fetal loss ment is cause for concern 5. Benefits 2. Methods for performing FMC—adjusted to a. Provides early diagnosis and may decrease client’s abilities with instructions to count fetal morbidity and mortality if elective abor- movements starting at 28 wks (identifiable risk tion (AB) is sought present) or 34–36 weeks (low risk for uteropla- b. May decrease psychological stress; sup- cental insufficiency) port systems can be established prior to a. Sanovsky’s Protocol delivery Techniques Used to Assess Fetal Health 95

(1) Count FM 30 minutes three times d. NSTs may be affected by any of the daily; four or more movements in a following: 30-minute period is reassuring (1) Fetal sleep (2) If less than four movements in a (2) Smoking within 30 minutes of testing 30-minute period, then continue for 1 (3) Maternal intake of medications hour (4) Fetal CNS anomalies (3) Contact care provider if fewer than 10 (5) Fetal hypoxia and/or acidosis movements or if movements become e. A nonreactive NST may be followed by a weak BPP, a contraction stress test, or a repeat b. Cardiff “Count to 10” method NST (1) A chart to check off 10 fetal move- f. If indicated, NSTs should be repeated ei- ments in one counting session ther weekly or biweekly (2) Start at approximately the same time daily • Contraction stress test (CST)/Oxytocin chal- (3) Chart how long it took to count 10 lenge test (OCT)—assessment of fetal well-being movements by observing fetal heart rate response to uterine (4) If fewer than 10 movements in 10 contractions hours or amount of time to reach 10 1. Physiology movements increases, an NST should a. During uterine contractions placental ves- be performed sels are compressed and intervillous blood flow to the fetus is decreased • Nonstress testing (NST) b. A fetus who is compromised or hypoxic 1. Method to assess fetal well-being by observing does not have reserves the fetal heart rate response to fetal movement 2. Method 2. 75% of fetuses at 28 weeks will experience a. Test is conducted in hospital heart rate accelerations in association with b. Electronic fetal monitoring (EFM); fetal movement monitor the FHR response to uterine 3. External electronic fetal monitoring is used contractions to record fetal heart rate accelerations in re- c. Contractions may be spontaneous, the sponse to fetal movement result of administration of exogenous oxy- 4. Accelerations may be spontaneous or may be tocin, or from nipple stimulation induced by vibro-acoustic stimulation (VAS) d. An acceptable test is one with 3 con- 5. Fetal hypoxia depresses the medullary center tractions lasting 40–60 seconds that are in the brain that controls fetal heart rate re- palpable sponse resulting in depression of frequency or 3. Results amplitude of the fetal heart rate a. Negative—no late or variable 6. Indications for assessment of fetal well-being decelerations with NST include: b. Equivocal or suspicious—presence of non- a. Decreased fetal movement repetitive or nonpersistent decelerations, b. Postdates or long-term variability is absent c. Diabetes, hypertension, IUGR c. Positive—persistent late decelerations 7. Interpretation of results with 50% or more of the contractions a. Reactive—2 or more accelerations in fetal 4. Contraindications to CST heart rate of 15 or more beats per minute, a. Absolute—previous classical C-section or lasting for 15 seconds or more, within a 15 myomectomy, placenta previa, at risk for to 20-minute period preterm labor b. Nonreactive—FHR fails to demon- b. Relative—gestational age less than 37 strate the required accelerations within weeks, multiple gestation a 40-minute period, requiring further evaluation • Biophysical profile (BPP)—procedure utilizing c. Unsatisfactory or inconclusive—fetal ultrasound to evaluate five fetal variables to assess heart rate tracing that is uninterpretable fetal risk; prospective studies have demonstrated or of poor quality, sometimes caused by that BPP is superior to CST as a predictor of fetal a vigorous infant; test should be repeated well-being or distress (individual site protocols vary) 1. Method a. Test is composed of five observable variables—NST, muscle tone, breathing 96 Chapter 4 Pregnancy

movements, gross body movements, and 3. Different tests may be used to assess the fac- amniotic fluid volume tors that help prevent atelectasis b. In addition to NST, the fetus is evaluated 4. Prior to 39 weeks’ gestation, there should be an via USG for a 30-minute time period to evaluation of fetal lung maturity if labor induc- observe the remaining four variables tion or Cesarean delivery is electively sched- 2. BPP scoring—each of the five variables is uled to help prevent iatrogenic prematurity scored from 0 (abnormal) to 2 (normal); the and respiratory distress syndrome scores for each are totaled a. Lecithin/sphingomyelin ratios (L/S) a. Breathing movements—one or more epi- (1) Lecithin is elevated after 35 weeks sodes in 30 minutes; none = 0, present = 2 (2) Sphingomyelin remains fairly b. Body movement—three or more discrete constant body or limb movements in 30 minutes; (3) Ratio of 2:1 or greater is indicative of none = 0 present = 2 fetal lung maturity except in diabetes c. Tone—one or more episodes of extension (4) L/S ratio may also not be accurate in with return to flexion; none = 0, present = 2 hydrops fetalis and nonhypertensive d. Qualitative amniotic fluid volume (AFV)— glomerulonephritis at least one pocket of amniotic fluid that b. Phosphatidylglycerol (PG) measures at least 2 cm in 2 perpendicular (1) Appears after 35 weeks when lungs are planes; none = 0, present = 2 mature e. Reactivity—reactive NST; nonreactive (2) If PG present, in combination with scored as 0, reactive = 2 a favorable L/S ratio, confirms lung 3. Scoring interpretation criteria maturity a. 8–10 is normal (in absence of c. Shake test oligohydramnios) (1) Amniotic fluid is shaken in a tube with b. 6 is equivocal, repeat testing saline and 95% ethanol for 15 seconds c. 4 or less is considered abnormal (2) A complete ring of bubbles on the sur- 4. Modified BBP, NST, and amniotic fluid in- face is indicative of fetal lung maturity dex—(see Postterm pregnancy section in this (3) Advantage of this procedure is it can chapter) be conducted at the bedside (4) Has a low false positive rate • Percutaneous umbilical blood sampling (PUBS or (5) Has a high false negative rate cordocentesis) d. Foam stability test 1. Definition—process in which a needle is intro- (1) Similar to the shake test but amniotic duced under real-time ultrasound, through the fluid is shaken with various amounts maternal abdomen and then into the umbili- of 95% ethanol only cal cord; blood is then aspirated or blood and/ (2) Foam formation is indicative of lung or medications are introduced into the fetus maturity 2. Usually performed after 20 weeks (3) Collection of amniotic fluid 3. Used for prenatal diagnosis—Rh (anti-D) dis- (4) With intact membranes, fluid is ob- ease, fetal infections, blood factor abnormali- tained by amniocentesis ties, chromosomal or genetic disease, fetal (5) With ROM, fluid can be aspirated hypoxia assessment with a sterile syringe and sent for 4. Used to treat the fetus—fetal transfusion, ad- evaluation minister drug therapy e. Results 5. Concerns (1) L/S ratio should be above 2 a. Similar to amniocentesis and CVS (2) If PG is present even with an L/S ratio procedures of less than 2, the risk of respiratory b. Must be performed by a skilled individual distress syndrome is minimal able to secure immediate delivery and appropriate level of neonatal care Â Selected Obstetrical Complications • Methods to assess fetal lung maturity 1. Respiratory distress (RDS) is a major problem • Abuse associated with preterm birth 1. Substance abuse 2. Assessment of fetal lung maturity is accom- a. Substances with known potential for plished by assessing the amniotic fluid abuse/addiction (1) Legal drugs Selected Obstetrical Complications 97

(a) Alcohol—17 million (6.9% of US ectopic pregnancy, and premature population) report heavy drinking rupture of membranes (5 or more drinks/occasion on 5 (b) Infant effects—IUGR, premature or more days in last 30 days) birth, and small for gestational (b) Nicotine—71 million (28.6% of US age population) currently use tobacco (2) Alcohol products (a) Maternal effects—spontaneous (2) Illegal drugs—prevalence in 2007 was abortion and possibly some 19.9 million in US (8.0%) reporting use subtle neurologic problems in in past month school-age child (a) Cocaine (b) Infant effects—fetal alcohol syn- (b) Hallucinogens drome (FAS), fetal alcohol effects (c) Heroin (FAE), or alcohol-related birth de- (d) Marijuana fects (ARBD) (e) Nonmedical use of prescription (3) Illicit drugs psychotherapeutics and pain (a) Effects less well known, and relievers knowledge of long-term implica- b. Historical evolution of the concept of alco- tions is limited hol use in the US (b) Research findings confounded by (1) After WWII, dominant view linked social and economic factors excessive use of prescription drugs, (c) Polydrug use further confounds alcohol, and use of illicit drugs with the reality emotional instability, weak will, and (d) Maternal effects of heroin and poor character methadone—eclampsia, placen- (2) Jellinek’s 1960 disease model for alco- tal abruption, IUGR, intrauterine holism made it a chronic, relapsing death, postpartum hemorrhage, disease with a genetic component preterm labor, premature rupture (3) Major definition shift paved the way of membranes for the Alcoholics Anonymous ap- (e) Infant effects—jitteriness, hy- proach to treatment perreflexia, restlessness, sleep- c. Substance abuse in pregnancy lessness, poor feeding pattern, (1) Prevalence—Substance Abuse and vomiting, diarrhea, shrill cry Mental Health Services Administra- f. Screening tion (SAMHSA, 2009) (1) Toxicology screen; most commonly (a) 16.4% smoked done on maternal urine; more re- (b) 10.6% drank some alcohol cently, meconium, infant hair sample, (c) 4.5% engaged in binge drinking amniotic fluid, cord tissue (d) 5.1% used illegal drug in past (2) History—more information gathered month regarding length of time and quantity d. Factors associated with increased risk for of use substance abuse in pregnancy include: (3) Combination of both (1) Lack of education g. Screening tools for alcohol use (2) Low self-esteem (1) CAGE (3) Depression C–have you felt the need to cut down (4) Family problems and/or family his- on your drinking? tory of substance abuse A–have people annoyed you by criti- (5) Financial problems and poverty cizing your drinking? (6) Abusive relationships G–have you ever felt bad or guilty (7) Feelings of hopelessness about your drinking? (8) Drug-abusing partner E–have you ever had a drink first thing e. Maternal medical and obstetrical compli- in the morning to steady your nerves cations of substance abuse include: or get rid of a hangover (eye-opener) (1) Smoking (2) TWEAK (a) Maternal effects—preeclampsia, Tolerance—how many drinks can you abruption placentae, placenta hold? previa, spontaneous abortion, 98 Chapter 4 Pregnancy

Worried—have close friends or rela- (2) Emotional tives worried or complained about (a) Engages in name calling or insults your drinking in the past year? (b) Isolates from family and friends Eye openers—do you sometimes take (c) Publicly humiliates a drink in the morning when you first (d) Makes all decisions get up? (e) Withholds affection Amnesia—has a friend or family (3) Sexual member ever told you about things (a) Treats women as sex objects you said or did while you were drink- (b) Forces sexual acts with self or ing that you could not remember? others Cut down—do you sometimes feel the (c) Jealous anger with accusations need to cut down on your drinking? (d) Withholds sex and affection h. Management (e) Engages in sadistic sexual acts (1) Ideal—stop using harmful substances (4) Financial (2) Reduce quantity and types of sub- (a) Withholds money stances used (b) Runs up bills woman must pay (3) Mobilize resources to support and (c) Makes all monetary decisions encourage (d) Manipulates relationship through (4) Drug rehabilitation money i. Ethical considerations—who should be d. Diagnosis of abuse screened? (1) History (1) Universal and mandatory versus none (a) Depression or suicide attempts for anyone (b) Substance abuse (2) Screening of those with positive his- (c) Childhood abuse (sexual or tory or who exhibit signs of use physical) j. Legal implications (d) Multiple injuries (1) Mandatory reporting to child protec- (e) Complaints of chronic pain tive services (f) Repeated spontaneous abor- (2) Possible loss of infant tions (SAB), threatened abortions (3) Criminal prosecution of woman (TAB), and/or STD 2. Intimate partner abuse/Violence against (2) Physical women (VAW) (a) Assessing for injuries—multiple a. Incidence of VAW—more than half of all bruises in various stages of recov- women experience some form of abuse at ery; proximal vs distal—proximal some point in their lives tends to be intentional; hidden b. Screening techniques for ascertaining injuries—breasts, abdomen, back, the presence of VAW; essential questions etc. asked during history taking include: (b) Treatment delays—old scars or (1) Have you ever been emotionally or bruises visible physically abused by your partner or (c) Patterned injuries—with reason- someone important to you? able certainty can determine what (2) Within the past year, have you been kind of object caused injury, e.g., hit, slapped, kicked, shoved, or other- bite marks wise hurt by anyone? (d) Physical findings inconsistent (3) Have you ever been hit, slapped, with history kicked, or otherwise physically hurt (e) Genital trauma, vaginismus while you were pregnant? (f) Poor weight gain in pregnancy c. Definitions of VAW (3) Others (1) Physical (a) Partner appears “overprotective” (a) Pushes, slaps, punches (b) Missed appointments (b) Locks woman in or out of the e. Effect of pregnancy on VAW house f. Risks in pregnancy in the situation of (c) Refuses to buy food violence/abuse, to the woman and fetus (d) Refuses access to medical care g. Management (e) Destroys property or pets (1) Data collection (f) Abuses children (2) Forensic examination (3) Safety Selected Obstetrical Complications 99

(4) Counseling a. Spontaneous abortion—occurring without (5) Acute intervention apparent cause (6) Long-term aid b. Threatened abortion—appearance of (7) Referral signs and symptoms of possible loss of the h. Community resources for victims of fetus, i.e., vaginal bleeding with or without violence/abuse intermittent pain i. Legal and emergency issues related to do- c. Inevitable abortion—cervix is dilating, mestic violence uterus will be emptied d. Incomplete abortion—an abortion in • First trimester bleeding which part of the products of conception 1. Definition—bleeding occurring within the first has been retained in the uterus 12 weeks of pregnancy e. Complete abortion—all the products of a. 40% of women have some bleeding in the conception have been expelled first trimester f. Missed abortion—the fetus died before b. 80% of spontaneous abortions occur in completion of 20 weeks’ gestation but the first 12 weeks products of conception are retained for c. 90% of pregnancies with bleeding will a prolonged period of time (2 or more continue to term after FHT observed weeks) 2. Differential diagnosis g. Habitual abortion—three or more con- a. Implantation bleeding secutive abortions b. Threatened abortion 2. Etiology—fetal factors c. Ectopic pregnancy a. Abnormal development of zygote such as d. Cervicitis chromosomal abnormalities is responsible e. Cervical polyps for about 60% f. Vaginitis b. Autosomal trisomy is the most frequently g. Trauma/Intercourse identified chromosomal anomaly, fol- h. Disappearing twin lowed by Turner’s syndrome i. Autoantibody/autoimmune disorder 3. Etiology—maternal factors 3. Diagnosis a. Incidence increases with parity and/or a. Pelvic examination short interconceptional period (1) Speculum examination to visualize b. Incidence increases with maternal and the cervix paternal age (2) Bimanual examination to assess 4. Common causes of spontaneous abortion uterus and adnexa for size and a. Anatomic anomalies tenderness b. Infections (3) Laboratory diagnosis c. Immune factors, including autoimmune (a) Serum hCG is positive 8–9 days clotting disorders after fertilization d. Endocrine effects (b) b-hCG doubles every 48 hours e. Recreational drugs/ETOH/environmental with normal intra-uterine preg- toxins nancy (IUP) (1) Smoking (c) b-hCG increases by only one third (2) ETOH when an ectopic pregnancy exists (3) Caffeine (4) Rule of 10 (4) Radiation (a) b-hCG equals 100 at time of (5) Cocaine missed menses (6) Anesthetic gasses/surgery (b) b-hCG is 100,000 at 10 weeks f. Severe malnutrition (peak) g. Age of gametes (c) b-hCG 10,000 at term 5. Management (d) b-hCG elimination half-life about a. Obtain blood type if not known 24 hours b. Draw baseline serum b-hCG (e) 90% of ectopics have b-hCG less c. Repeat b-hCG in 48 hours than 6500 d. Ultrasound 4. Treatment—depends on etiology e. Should be able to visualize transabdominally an IUP at hCG of 6500 • Spontaneous abortion f. Should be able to visualize transvaginally 1. Types of abortion an IUP at hCG of 2000 100 Chapter 4 Pregnancy

g. RhoGAM for unsensitized Rh negative b. Serum b-hCG (90% of ectopics have women b-hCG less than 6500; abnormal interval increases) • Inevitable or incomplete abortion c. Ultrasound 1. Surgical D&C d. Culdocentesis 2. Chemical D&C e. Laparoscopy 3. Observant management 10. Differential diagnosis 4. Emotional support and anticipatory guidance a. PID b. Ovarian cyst • Threatened abortion or disappearing twin c. Appendicitis 1. Pelvic rest 11. Management 2. Emotional support and anticipatory guidance a. Consult and transfer to medical management • Ectopic pregnancy b. Tubal preservation is the goal 1. Definition—implantation of the blastocyst c. Salpingectomy/salpingostomy/tubal anywhere other than the endometrium resection 2. 95% of ectopic pregnancies occur in the fallo- d. Methotrexate pian tube e. RhoGAM for Rh-negative unsensitized 3. Second leading cause of maternal death in US women 4. Occurs in about 1 per 85 pregnancies; rate is highest in the 35–44 year age group • Hydatidiform mole 5. Etiology 1. Incidence—1:1500 to 1:2000 a. STD—especially chlamydia and gonorrhea 2. Highest incidence at beginning and end of re- b. Therapeutic abortion followed by productive years with greatest incidence after infection age 45 c. Endometriosis 3. Symptoms d. Previous pelvic surgery a. Abnormal uterine bleeding e. Failed bilateral tubal ligation b. Size/dates discrepancy f. Mechanical—problems with tubes such as c. Lack of fetal activity scarring d. Hyperemesis gravidarum g. Functional—menstrual reflux, hormonal e. Gestational hypertension before 20 weeks alteration of tubal motility f. Passage of vesicular tissue 6. Sites for ectopic 4. Diagnosis a. Ampulla—78% of ectopics a. Ultrasound b. Isthmus—12% of ectopics b. Serum b-hCG c. Interstitial—2% of ectopics 5. Management d. Fimbria—less than 1% of ectopics a. Uterine evacuation by suction curettage e. Other sites—abdominal, ovarian, and b. Close surveillance for persistent tropho- broad ligament blastic proliferation or malignant changes 7. Symptoms c. Recommend avoidance of pregnancy for 1 a. Amenorrhea but frequently has some vagi- year nal spotting d. Serial b-hCG levels every 2 weeks until b. Lower pelvic and/or abdominal pain, normal then once a month for 6 months, which is unilateral then every 2 months for 1 year c. Unilateral tender adnexal mass e. Chest radiograph d. Some have no symptoms 8. Clinical picture • Second trimester bleeding—bleeding is less a. Severe abdominal pain common b. Cervical motion tenderness 1. Midtrimester spontaneous abortion c. Free fluid on ultrasound a. Etiology d. Cul-de-sac fullness (1) May be associated with autoimmune e. Shoulder pain second to diaphragmatic disorders irritation (2) May be related to cocaine use f. Vertigo or fainting (3) May be related to anatomic or physi- 9. Diagnosis ologic factors a. Physical examination 2. Incompetent cervix a. Symptoms Selected Obstetrical Complications 101

(1) Painless dilation e. Diagnosis (2) Bloody show (1) History (3) Spontaneous rupture of membranes (2) Ultrasound (4) Vaginal/pelvic pressure f. Management b. Risk factors (1) Consult, in some practices may (1) Previous midtrimester loss comanage (2) Cervical surgery (2) Observant management until delivery (3) DES (3) If bleeding, hospitalize c. Treatment (4) Tocolytic therapy may be considered (1) Consult (5) May be able to deliver vaginally if (2) Cervical cerclage after 12–14 weeks bleeding is not severe and os is not (3) Success rate of 80–90% completely covered (4) Risk of ruptured membranes or (6) If vaginal birth is considered will need infection double set-up for birth (5) Monitor cervical length via transvagi- (7) If complete previa, medical manage- nal ultrasound ment and Cesarean birth 3. Placental anomalies 4. Placental abruption (cause of 30% of third tri- a. Low-lying placenta mester bleeds) (1) One third of women have low-lying a. Definition—premature separation of the placenta in first trimester placenta from the uterus that may be par- (2) Only 1% have previa in the third tial or complete trimester b. Risk factors b. Partial abruption (1) Hypertension—chronic or gestational (1) May resolve (2) Trauma (2) May reabsorb (3) Smoking c. Diagnosis (4) Cocaine use (1) Ultrasound (5) Multiparity (2) Consult as needed (6) Uterine anomalies or tumors c. Signs and symptoms • Third trimester bleeding (1) Vaginal bleeding 1. Incidence—4% of all pregnancies (2) Uterine tenderness and rigidity 2. Never perform a digital vaginal examination (3) Contractions or uterine irritability on a woman’s cervix in the presence of third and/or tone trimester bleeding unless certain there is no (4) Fetal tachycardia or bradycardia previa! d. Complications 3. Placenta previa (responsible for 20% of third (1) Shock trimester bleeds) (2) Fetal compromise or death a. Definition—placenta is located over or (3) Disseminated intravascular coagula- next to the internal cervical os; may be tion (DIC) partial (not totally covering the os), mar- e. Diagnosis ginal (palpable at margin of os) or com- (1) Clinical evaluation plete (completely covering the os) (2) Fetal monitoring b. Incidence (3) Ultrasound (1) From 0.4 to 0.6% f. Management (2) Occurs in 1 of 300 pregnancies (1) “Get help” c. Risk factors (2) Monitor clotting studies and hgb/hct, (1) Multiparity platelets (2) Previous C-section or other uterine (3) Stabilize mother surgery (4) Effect delivery as indicated by fetal or (3) Smoking maternal condition d. Signs and symptoms (1) Primary—associated with painless • Selected problems during pregnancy vaginal bleeding 1. Birth defects or anomalies—common terms (2) Secondary—unengaged fetal presen- and definitions tation and/or malpresentation a. Malformation—the fetus or structure is (3) Sometimes bleeding is associated with genetically abnormal, e.g., limb contrac- contractions ture resulting from diastrophic dysplasia 102 Chapter 4 Pregnancy

b. Deformation—a genetically normal fetus (2) Genome—the complete set of chro- develops in an abnormal uterine environ- mosomes or the entire genetic infor- ment causing structural changes, e.g., oli- mation present in a cell gohydramnios causing limb contractures (3) Euploidy—state of complete sets of c. Disruption—a genetically normal fetus chromosomes suffers an insult resulting in disruption of (4) Aneuploidy—state of having an abnormal development, e.g., early amnion normal number of chromosomes rupture causing limb deformities (5) Polyploidy—abnormal number of d. Syndrome—multiple abnormalities have haploid chromosome complements the same cause, e.g., trisomy 18 (6) Deletion—portion of a chromosome e. Sequence—abnormalities occurred se- that is missing quentially as result of one insult, e.g., (7) Ring chromosome—when deletions oligohydramnios leading to pulmonary occur at both ends of the chromo- hypertension, limb contractures, and fa- some, the ends may untie to form a cial deformities ring f. Association—set of abnormalities that fre- (8) Isochromosomes—composed of ei- quently occur together but have no linked ther two short arms or two long arms etiology of the chromosome fused together 2. Genetic abnormalities e. Trisomy 21—Down syndrome, the most a. Critical concept definitions common, nonlethal trisomy (1) Phenotype—the expression of genes (1) Incidence—1 in 800–1000 newborns present in an individual, e.g., eye (2) Etiology—almost 95% due to nondis- color, blood type, etc. junction of maternal chromosome 21 (2) Genotype—the total hereditary infor- (3) Signs and symptoms mation present in an individual; the (a) Marked hypotonia pair of genes for each characteristic (b) Tongue protrusion b. Definitions of critical patterns of (c) Small head inheritance (d) Flattened occiput (1) Single-gene (Mendelian) disorders (e) Flat nasal bridge (a) A mutation in a single locus or (f) Epicanthal folds and slanting gene, in one or both members of a palperbral fissures gene pair (g) Nuchal skin fold (b) Incidence—0.4% by age 25; 2% (h) Short, stubby fingers during lifetime (i) Single palmar crease (2) Autosomal dominant—when only one (j) Fifth fingers are curved inward member of a gene pair determines the (k) IQ range—25–50 phenotype, e.g., BRCA 1 and 2 breast (4) Recurrence risk—1% until age-related cancer risk status reached after age 35 (3) Autosomal recessive—trait is ex- f. Genetic counseling pressed only when both copies of the (1) Goals for first step—to educate the gene are the same, e.g., cystic fibrosis, woman and her family about testing sickle cell anemia options, indications for and implica- (4) Sex-linked tions of results (a) X-linked diseases are usually (2) Goals after abnormal screen—to in- recessive, e.g., color blindness, form woman of options to address the hemophilia results (b) Y-linked diseases relate to sexual (3) Indications for genetic studies determination, cellular functions, (a) General screening for anomalies, and bone development e.g., neural tube defect, Trisomy c. Inborn errors of metabolism—autosomal 21 recessive disease resulting from absence of (b) History of birth defects or mental an essential enzyme causing incomplete retardation metabolism of proteins, fats, or sugars, (c) Family history of genetic e.g., PKU disorders d. Definition of essential terms (d) Exposure to teratogens (1) Autosome—any chromosome other (e) Ingestions of medications in than sex (X or Y) chromosomes early pregnancy known to be Selected Obstetrical Complications 103

teratogenic, i.e., seizure preven- iii. Repeat, or do a nontrepone- tion drugs mal screening at time of (f) Has increased likelihood due to delivery age or ethnic roots (f) Treatment—98% effective 3. Sexually transmitted infections (Centers for i. Penicillin—dual purpose in Disease Control and Prevention, 2006) pregnancy; eradicate ma- a. Definition—transmission of pathogens ternal infection and prevent through sexual activities and behaviors infection in the newborn b. Incidence—relatively common during ii. Early syphilis—benzathine pregnancy penicillin G 2.4 million units c. Diseases characterized by genital ulcers IM; some recommend a sec- (1) Syphilis ond dose in 1 week particu- (a) Incidence—3.8 cases per 100,000 larly for secondary stage or in persons (2007) third trimester (b) Clinical manifestations—primary iii. Syphilis of more than 1 year syphilis duration—benzathine peni- i. Incubation—10–90 days, usu- cillin G 2.4 million units IM ally less than 6 weeks weekly 3 3 doses ii. Primary genital lesion diffi- (g) Penicillin allergy cult to see, goes unnoticed— i. Skin test to confirm allergy cervical chancre more ii. Desensitize, then treat as common in pregnancy above iii. Painless firm ulcer with raised (h) Congenital syphilis or stillbirth— edges may be only sign of maternal iv. Heals after 2–6 weeks; may infection have nontender enlarged in- i. Incidence—historically guinal lymph nodes accounted for 30% of all (c) Clinical manifestations—second- stillbirths ary syphilis ii. US 1998—30 per 100,000 i. Variable skin rash appears births 4–10 weeks after chancre (i) Jarisch-Herxheimer reaction heals i. Acute febrile reaction often ii. Not noticed in 25%—may be with headache and myal- limited to genitalia gia occurring within first 24 iii. Condylomata lata—elevated hours of treatment initiation; areas that may cause vulvar not an allergic reaction; most ulcerations common in early syphilis iv. Alopecia sometimes occurs treatment (d) Etiology ii. Might induce early labor or i. Chronic infection—spiro- cause fetal distress; should chetes cause lesions in major not prevent or delay therapy organs iii. Advise pregnant women of ii. Recent infection more likely this possible reaction to affect fetus iv. May use antipyretics for iii. Placental changes—large, symptoms; resolves in 24 pale hours (e) Diagnosis (2) Herpes Simplex virus (HSV) i. VDRL or RPR—first prenatal (a) Incidence—at least 50 million in visit US have been infected with HSV-2 ii. Fluorescent treponemal (CDC, 2006) antibody absorption test (b) Signs and symptoms—primary (FTA-ABS) or microhemag- infection glutination assay for antibod- i. Incubation—3–6 days ies to Treponema pallidum ii. Pruritic papular eruption that (MHA-TP) confirms nonspe- becomes painful and vesicu- cific VDRL/RPR lar, multiple lesions iii. Inguinal adenopathy 104 Chapter 4 Pregnancy

iv. Transient flu-like symptoms (a) Incidence—119 cases per 100,000 v. By 2–6 weeks all signs and population (CDC, 2007); highest symptoms are gone in 15–19 year age group (c) Signs and symptoms—recurrent (b) Prevalence in pregnancy—varies infection with high at 7% i. Reactivation results in virus (c) Risk factors—single, adolescence, shedding poverty, drug abuse, prostitution, ii. Signs and symptoms are less concomitant STD, lack of an- intense but occur at same site tepartal care (d) Diagnosis (d) GC is marker for chlamydia i. Viral culture or PCR detection (e) Diagnosis—screen at first visit; ii. Type-specific serologic tests repeat at 28 weeks in high-risk (e) Treatment groups i. Antivirals—acyclovir, valacy- (f) Clinical significance in preg- clovir—primary or first epi- nancy—associated with septic sode infection, symptomatic spontaneous or induced abortion recurrent episode; daily sup- (g) Treatment pression from 36 weeks’ gesta- i. Single dose ceftriaxone 125 tion until delivery mg IM, or cefixime 400 mg ii. Analgesics and topical orally or spectinomycin 2 g anesthetics IM (f) Management of birth—Cesarean ii. Concomitant treatment for delivery indicated only if woman chlamydia if infection is not has active genital lesions or pro- ruled out dromal symptoms (2) Chlamydia trachomatis (CT) (3) Human papillomavirus (HPV) (a) Incidence—370 cases per 100,000 (a) Incidence—symptomatic or population (CDC, 2007); most asymptomatic is common common reportable STD (b) HPV type and associated (b) Risk factors—age younger than conditions 25, presence or history of STD, i. HPV-16—cervical, vaginal multiple partners, new sexual and vulvar neoplasia partner in last 3 months ii. HPV-6, 11, also 16, 18, 30s, (c) Signs and symptoms—urethritis, 40s, 50s, 60s—condylomata mucopurulent cervicitis, acute acuminata salpingitis iii. HPV-16, 18, 45, 56, 31, 33, 35, (d) Differential diagnosis—normal 39, 51, 52, 58, 66—cervical pregnancy, cervical mucus intraepithelial neoplasia and (e) Diagnosis—NAAT is most specific cancer and sensitive test available (c) Treatment (f) Treatment i. Imiquimod, podophyllin, i. Tetracyclines and quino- podofilox are contraindicated lones are contraindicated in pregnancy in pregnancy ii. Cryotherapy, trichloracetic ii. Azithromycin 1 g orally, acid (TCA), surgical removal if single dose or amoxicillin indicated 500 mg orally tid for 7 days (d) Management of birth—Cesarean recommended delivery should not be used solely iii. Alternative regimes—various to prevent transmission to new- dosing regimens of erythro- born; Cesarean delivery may be mycin base or ethylsuccinate indicated if genital warts obstruct iv. Repeat testing 3 weeks after pelvic outlet or if vaginal delivery completion of treatment would result in excessive bleeding e. Diseases characterized by vaginal d. Diseases characterized by urethritis/ discharge cervicitis (1) Bacterial vaginosis (BV) (1) Gonorrhea (a) Associated with premature rupture of membranes, Selected Obstetrical Complications 105

chorioamnionitis, preterm labor (a) Congenital infections and birth, intra-amniotic infec- (b) Chromosomal abnormalities tion, postpartum endometritis, (c) Maternal drug use—tobacco, al- postCesarean wound infection cohol, dilantin, cocaine, heroin (b) Treatment in pregnancy (3) Increased risk of adverse long-term i. Treat all symptomatic preg- sequelae nant women and asymptom- e. Asymmetric growth restriction atic pregnant women at high (1) Appears later in the pregnancy risk for preterm delivery (2) Asymmetry is caused by a reduction in ii. Metronidazole 250 mg orally cell size, not number of cells resulting tid or 500 mg bid for 7 days in “head-sparing” iii. Clindamycin 300 mg orally (3) Due to abnormalities in uteroplacen- bid for 7 days tal perfusion (2) Trichomoniasis (4) Caused by (a) Associated with premature rup- (a) Maternal factors ture of membranes, preterm de- i. Hypertension livery, low birth weight ii. Anemia (b) Treatment in pregnancy iii. Collagen disease i. No data to support treatment iv. IDDM reduces perinatal morbidity (b) Placental factors ii. Metronidazole 2 g orally i. Previa single dose or 500 mg bid for ii. Abruption 7 days iii. Malformations (3) Vulvovaginal candidiasis (VVC) iv. Infarctions (a) Treatment of uncomplicated VVC (c) Fetal factors in pregnancy—topical treatment i. Multiple gestation with azoles for 7 days—butocon- ii. Anomalies azole, clotrimazole, miconazole, (5) Diagnosis terconazole, nystatin (a) Review history (b) Treatment of recurrent or severe (b) Physical examination VVC in pregnancy—may require i. Fundal height longer duration of therapy with ii. EFW topical azoles (c) Ultrasound to confirm diagnosis 4. Small for gestational age (SGA) and intrauter- i. Anomalies ine growth restriction (IUGR) ii. Serial studies for growth a. Definitions—small for gestational age iii. AFI (SGA), intrauterine growth restriction iv. Doppler flow studies (IUGR) or fetal growth restriction are v. Placenta grading and terms used interchangeably to describe assessment a fetus or newborn whose size is smaller (6) Fetal effects than the norm. IUGR is used to describe (a) Fetus adjusts to conditions by impaired or restricted intrauterine growth conserving energy and decreasing and is considered a pathologic process. metabolic requirements SGA is a neonatal diagnosis and describes (b) Fetus stops growing an infant who falls below the 10th percen- (c) Risk of intrauterine fetal demise tile. The majority of SGA babies are IUGR. (7) Management b. Differentiation (a) Consult (1) The genetic design of a constitution- (b) If you are able to identify a cause, ally small infant (parents are also counsel and make adjustments small) i. Decrease smoking (2) Low birth weight secondary to poor ii. Nutrition evaluation nutrition iii. Maternal positions that fa- c. Incidence—3–8%; leads to 18% mortality cilitate uteroplacental blood rate flow, left lateral or sitting d. Symmetric growth restriction iv. Emotional support and an- (1) Appears around 18–20 weeks ticipatory guidance (2) Caused by (c) Serial ultrasounds for growth 106 Chapter 4 Pregnancy

(d) Serial NSTs and AFI or BPPs (2) Abruptio placenta (weekly or biweekly) (3) Uterine overdistention—multiple ges- (e) TORCH titer tation, polyhydramnios (f) Amniocentesis, chromosome (4) Cervical incompetence evaluation of parents (5) Hormonal changes perhaps mediated (g) If lungs are mature, consider by fetal or maternal stress delivery (6) Acute inflammatory response 5. Large for gestational age (LGA)/macrosomia (7) Bacterial infections—urinary tract or a. Definition—in US babies weighing more genital tract than 4000 g at birth (macrosomia) or over (8) Poor nutritional status the 90th percentile in weight for gesta- (9) Prepregnancy underweight and inad- tional age equate gain during pregnancy b. Risk factors (10) Previous history of preterm labor and (1) Ethnic/racial origins birth (2) Obesity (11) Short interval between pregnancies (3) Previous LGA/macrosomic neonate (12) Substance abuse—cocaine, alcohol, (4) Previous shoulder dystocia cigarettes (5) Size of the father (13) Chorioamnionitis (6) Birth weight of both the mother and (14) Placenta previa the father (15) Fetal death (7) Diabetes or history of gestational (16) Preterm premature rupture of diabetes membranes (8) Previous uterine myomata (17) Preeclampsia (9) Multiparity d. Risk scoring systems to identify women c. Physical examination at risk for preterm birth have not been (1) Fundal height successful (2) EFW and palpation of fetal parts e. Signs and symptoms (3) Maternal body habitus (1) Painful or painless uterine d. Differential diagnosis contractions (1) Inaccurate dating (2) Pelvic pressure (2) Polyhydramnios (3) Menstrual-like cramps (3) Multiple gestation (4) Watery or bloody vaginal discharge (4) Diabetes (5) Low back pain (5) Uterine fibroids f. Markers for predicting preterm birth e. Management (1) Fetal fibronectin (fFN) screening (1) Discuss risks/challenges (a) Use only in women at high risk for (2) Diet counseling preterm birth (3) Ultrasound for EFW (b) fFN normally present in cervi- (4) Carefully assess clinical pelvimetry cal secretions until 16–20 weeks’ (5) Consult gestation and then again late in (6) Monitor for shoulder dystocia pregnancy 6. Preterm birth (c) Negative test results useful in rul- a. Definition—a combination of prematurity, ing out imminent (within 14 days) expressed as a birth at 37 weeks’ gestation preterm birth before 37 weeks’ or earlier and low birth weight, indicated gestation (predictive value up to by infant weight of 2500 g or less; with im- 94%) proved neonatal care, the greatest contri- (d) Positive test at 24–34 weeks may bution to mortality and serious morbidity predict imminent preterm birth comes from infants of less than 34 weeks’ (predictive value 46%) gestation (2) Home uterine activity monitoring— b. Incidence of preterm birth by gestational data insufficient to support use in pre- age—11.6% of births are 37 weeks or less venting preterm birth of which 1.93% are less than 32 weeks (US (3) Endocervical length NCHS, 2000) (a) Cervical shortening determined c. Factors associated with preterm birth with ultrasound associated with (1) Largely unknown preterm birth Selected Obstetrical Complications 107

(b) Usefulness limited by lack of affects fetus, i.e., necrotizing proven treatments to affect enterocolitis, intracranial outcomes hemorrhage g. Diagnosis—ACOG and AAP criteria for iv. Calcium-channel blockers- 20–37 weeks’ gestation nifedipine; shows prom- (1) Contractions—4 in 20 minutes or 8 in ise but not adequately 60 minutes plus progressive change in researched yet the cervix v. Oxytocin analog—atosiban; (2) Cervical dilatation greater than 2 cm research to date shows it did (3) Cervical effacement of 80% or more not improve infant outcomes h. Management—goal is to delay preterm 7. Multiple gestation—identify as early as birth (prior to 34 weeks) and enhance in- possible fant’s resources to cope with life outside a. Incidence the uterus (1) Monozygotic—4/1000 worldwide (1) Premature rupture of membranes— (2) Dizygotic—8/1000 worldwide two approaches (3) Accounts for less than 1% of births but (a) Expectant management/ more than 10% of perinatal mortality nonintervention until spon- (4) Incidence varies with race and in- taneous labor begins creases with age, parity, and heredity (b) Intervention with corticosteroids b. Dizygotic (DZ) (fraternal)—fertilization of in conjunction with or with- two separate ova by two separate sperm out tocolytics to advance fetal (1) Use of fertility drugs increases chance maturation (2) Clomid—1/10 risk (c) Birth is inevitable but delaying (3) Gonadotropins—1/5 risk the birth seems to decrease infant (4) IVF increases risk mortality c. Monozygotic (MZ) (identical)—division of (d) Hospitalize a single egg fertilized by a single sperm (e) Corticosteroids (1) Risk factors are unknown (f) Antimicrobials (2) Time of ovum division determines (2) With intact membranes membrane development (a) Corticosteroids—clear benefits (a) Day 0–3—dichorionic, diamniotic for birth at 24–34 weeks, but un- (30%) clear for 34 weeks or longer; treat- (b) Day 4–8—monochorionic, diam- ment is most effective when time niotic (68%) interval from rupture to birth is a (c) After day 8—monochorionic, minimum of 24 hours and a maxi- monoamniotic (2%) mum of 7 days (d) After day 13 conjoined twins (b) Bed rest—ineffective to stop la- (< 1%) bor; associated with increased d. Family history increases risk risk of thromboembolic problems e. Clinical skills are important to identify (c) Hydration and multiple pregnancies sedation—ineffective f. Signs and symptoms (d) Tocolytic drugs (1) Fundal height greater than dates i. Beta-adrenergic receptor (2) Earlier or exaggerated discomforts of agonists—ritodrine and pregnancy terbutaline—relatively little (3) Two distinct heart beats effect with serious maternal (4) Outline of more than one fetus side-effects, i.e., pulmonary (5) Palpation of multiple small parts edema, cardiac insufficiency, (6) Ultrasound of two or more fetuses hyperglycemia, death g. Differential diagnosis ii. Magnesium sulfate—evi- (1) Macrosomia dence shows no effect for (2) Uterine, ovarian, or pelvic mass stopping labor and hyper- (3) Distended bladder magnesemia may have toxic (4) Polyhydramnios effect on mother and fetus (5) Hydatidiform mole iii. Prostaglandin inhibitors— (6) Inaccurate dates indomethacin; adversely h. Potential complications 108 Chapter 4 Pregnancy

(1) Hyperemesis (c) Footling or incomplete—one or (2) Preterm labor, PROM, preterm birth both feet or knees are lowermost (a) 36% deliver before 36 weeks’ (3) Etiology—some situation that distorts gestation the shape of the fetus or the uterus (b) 50% deliver before 37 weeks’ (a) Uterine septum gestation (b) Fetal anomaly, e.g., hydrocephaly (3) Low birth weight—55% are less than (c) Fetal attitude, e.g., extention of 5 lb spinal column or neck (4) Twin-to-twin transfusion (d) Placenta previa (5) Oligohydramnios (e) Conditions resulting in abnormal (6) Perinatal asphyxia fetal movement or muscle tone (7) Preeclampsia (4) Diagnosis (8) Postpartum hemorrhage (a) Abdominal examination—Leo- (9) Pyelonephritis pold’s maneuvers findings (four (10) Maternal anemia maneuvers) (11) Placental problems i. Fetal part in the fundus is (a) Previa round, hard, freely moveable (b) Abruption and ballotable (12) Fetal anomalies ii. Find back and small parts i. Antepartum management iii. Part in lower pole is large, (1) Consult nodular body (2) Discuss risks and benefits of manage- iv. Determine degree of engagement, serial ultrasounds, and regular ment and reaffirm previous fetal surveillance findings by confirming lack of (3) Counsel about maternal nutrition, cephalic prominence in lower rest, exercise, and stress pole (a) Increased nutritional needs (b) Vaginal findings compared to ver- (b) Increased iron tex findings (c) Small frequent meals i. No fetal skull sutures nor (d) Exercise limitations and bed rest fontanels are both controversial ii. Round indentation (anus) (4) Provide emotional support iii. Tissue texture is softer than (5) Evaluate weekly for weight, fetal head, if complete breech; growth, signs/symptoms of preterm toes, feet, or knees may be labor, and elevated BP palpated if footling (6) Preterm labor monitoring (5) Treatment (a) Possible administration of gluco- (a) External cephalic version corticoids for lung maturity (b) Moxibustion (b) Tocolytic therapy (c) Anticipatory guidance regarding (c) Birth plan should include avail- plan for version as well as plans ability of physician consultant for for persistent breech birth c. Shoulder—transverse lie in which the 8. Malpresentations of significance during the shoulder or arm is found in the lower pole prenatal period—breech and shoulder (trans- (1) Incidence—0.4% verse lie) (2) Etiology a. Concept—the presentation determines (a) Multiparity the presenting part (b) Placenta previa b. Breech—longitudinal lie with buttocks in (c) Polyhydramnios the lower pole (d) Uterine anomalies (1) Incidence 9. Hypertensive disorders of pregnancy (a) 14% between 29 and 32 weeks a. Definitions (b) 3.5% at term (1) Chronic hypertension—BP 140/90 (2) Variations mm Hg or higher diagnosed before (a) Frank—legs are extended up over pregnancy, before 20 weeks’ gestation, the fetal abdomen and chest or after 12 weeks postpartum (b) Complete—legs are flexed at the (2) Chronic hypertension with super- hips and knees imposed preeclampsia—chronic Selected Obstetrical Complications 109

hypertension with new-onset pro- (e) Hemoconcentration teinuria at greater than 300 mg in 24 (f) Thrombocytopenia hours, but no proteinuria before 20 (g) Hepatic dysfunction weeks’ gestation; or sudden increase (h) Elevated uric acid in proteinuria or blood pressure or d. Risk factors platelet count of less than 100,000/mm3 (1) Nulliparity in women with HTN and proteinuria (2) Adolescent or advanced maternal age before 20 weeks’ gestation (> 35 years) (3) Preeclampsia—the development of (3) Multiple gestation hypertension with proteinuria after (4) Family history of preeclampsia or the 20th week of pregnancy; varies in eclampsia degree (mild vs severe); only excep- (5) Obesity and insulin resistance tion is if the woman has a hydatidi- (6) Chronic hypertension form mole (7) Limited exposure to father of ba- (4) HELLP syndrome—Hemolytic ane- by’s sperm—new partner, donor mia, Elevated Liver enzymes, and Low insemination Platelet count (8) Antiphospholipid antibody syndrome (5) Eclampsia—seizures that cannot be and thrombophilia attributed to other causes in a woman e. Theory of causes with preeclampsia (1) Abnormal trophoblast invasion b. Management of chronic hypertension (2) Coagulation abnormalities (1) Consult—will need to comanage and/ (3) Vascular endothelial damage or transfer care (4) Cardiovascular maladaptation (2) Prepregnancy antihypertensive regi- (5) Immunologic phenomena men to be continued (precluding con- (6) Genetic predisposition traindicated medications) (7) Dietary deficiencies or excesses (3) Diuretics should not be used in f. Antepartum management of preeclampsia pregnancy (1) Consult diet assessment (4) First choice of antihypertensives in- (2) Adequate fluids clude labetalol or hydralazine (3) Restricted activities (some experts (5) Fetal surveillance advise) (a) Monitor for IUGR (4) Monitor BP, proteinuria, edema, (b) NSTs weight, intake and output, DTRs, sub- (c) AFI/BPP jective symptoms c. Classifications of preeclampsia—a range g. Laboratory tests of signs exist (1) Creatinine (1) Minimum criteria (2) Hgb/hct (a) BP $ 140/90 mm Hg (3) Platelets (b) Proteinuria 300 mg in 24 hours or (4) LFTs 1+ dipstick or greater (5) 24-hour urine for protein (2) Increased likelihood of preeclampsia (6) Creatinine clearance (a) BP 160/110 mm Hg or higher h. Assessment of fetus (b) Proteinuria 2.0 g/24 hour period (1) Daily fetal movement assessment or 2+ dipstick or greater (2) NST (c) Serum creatinine at greater (3) AFI/BPP than1.2 mg/dL (4) USG for growth (d) Platelets less than 100,000 mm3 i. Intrapartum management (e) Elevated ALT/AST (1) Goal to prevent seizures (f) Persistent headache, visual (2) Magnesium sulfate disturbance (a) Given IV (g) Persistent epigastric pain (b) Used as an anticonvulsant (3) Other signs and symptoms (c) Side-effects—flushing, (a) Severe headache somnolence (b) Cerebral or visual disturbances (d) Overdosage signs and symptoms (c) Right upper gastric or epigastric i. Loss of patellar reflex pain ii. Muscular paralysis (d) Edema iii. Respiratory arrest 110 Chapter 4 Pregnancy

iv. Aggravated by decreased c. Diagnosis

urine output (MgSO4 is ex- (1) Based on careful gestational age creted by kidneys) assessment (3) Antidote is calcium gluconate (a) Certain LNMP (4) Valium as anticonvulsant rarely used (b) Early examination (5) Antihypertensives (c) Sizing by bimanual examination (a) Hydralazine IV is antihypertensive (d) Fundal height of choice in severe preeclampsia (e) Fetal heart tones by doppler and (b) Others—labetalol (beta blocker), fetoscope nifedipine (2) Report of sexual history (6) Diuretics are not recommended— (3) Report of quickening woman is already volume depleted (4) Early USG gestational dating i. HELLP syndrome—affects 10% of patients (a) CRL best (between 6–14 weeks) with severe preeclampsia (b) Or dating using FL, AC, HC, and (1) Diagnosis BPD before 26 weeks (a) Hemolysis d. Potential complications (b) Abnormal peripheral blood smear (1) Shoulder dystocia—if fetus (c) Increased bilirubin at 1.2 mg/dL macrosomic or greater (2) Problems related to oligohydramnios (d) Elevated liver enzymes—AST, ALT, (3) Problems related to utero-placental LDH insufficiency (e) Platelet count at less than 100,000 (4) Neonatal meconium aspiration (2) Treatment (5) Stillbirth (a) Plasma volume expansion e. Management (b) Bedrest (1) Fetal movement counts between 40 (c) Crystalloids and 41 weeks (d) Albumin 5–25% (a) At 41 weeks begin biweekly NST/ (e) Delivery as indicated AFI or BPP (f) Magnesium sulfate (b) BPP if abnormal NST (CST used j. Eclampsia less frequently) (1) Signs and symptoms—same as pre- (c) Doppler velocimetry eclampsia with seizures (d) Consult (2) Management—medical management (e) Expectant management and (a) Magnesium sulfate delivery (b) Administer oxygen i. Consider induction when cer- (c) Safety—prevent injuries and min- vix is ripe imize aspiration during seizures ii. Prostaglandins may be used (d) Stabilize and deliver to promote cervical ripening k. Prevention of pregnancy-induced iii. Methods of labor induction— hypertension oxytocin, membrane strip- (1) Calcium and vitamin D supplemen- ping, amniotomy, nipple tation if at risk and have low dietary stimulation intake iv. Deliver if any indication (2) Low-dose aspirin—consider in high- of fetal compromise or risk pregnancies oligohydramnios 10. Postterm pregnancy v. Be prepared for possible a. Definition—pregnancy continuing beyond meconium staining of fluid 42 completed weeks’ gestation b. Incidence Â Medical Complications (1) 6–12% of pregnancies go beyond 42 weeks • Urinary tract infection (UTI) (2) 25% of postterm pregnancies result 1. Risk factors with babies who have postmaturity a. History of UTI syndrome b. Sickle cell trait (3) Associated with increased morbidity c. Diabetes and mortality d. Pregnancy Medical Complications 111

(1) The increased progesterone of preg- (6) If recurrent infection, consider sup- nancy causes relaxation of the smooth pressive therapy for the remainder of muscles of the GU tract the pregnancy (2) Decreased ureteral peristalsis and ure- (a) Nitrofurantoin 100 mg, orally at teral dilation present night (3) Physical pressure on bladder (b) Cephalexin 250 mg orally at night (4) Urinary stasis (7) Patient education (5) Incidence b. Pyelonephritis (a) Occurs in 2–7% of all pregnancies (1) Hospitalization (b) 25–30% will progress on to pyelo- (2) IV antibiotics nephritis if left untreated (3) Hydration 2. Cystitis; infection of the bladder (4) Antipyretics a. May be asymptomatic (asymptomatic (5) Monitor for preterm labor bacteriuria) b. Usual signs of UTI (although acute cystitis • Human immunodeficiency virus (HIV) (AIDS) is relatively rare in pregnancy) 1. Etiology—DNA retroviruses termed human c. Uterine contractions immunodeficiency viruses, HIV-1 and HIV-2; d. Suprapubic discomfort most cases worldwide are HIV-1; retroviruses e. Urgency and frequency have genomes that encode reverse tran- 3. Pyelonephritis—infection of the kidneys scriptase allowing the virus to make DNA cop- a. Fever and chills ies of itself in the host cells b. Nausea and vomiting 2. Incidence—approximately 25% of HIV- c. CVA tenderness positive adults in US are women; HIV/AIDS is d. Dysuria number one cause of death for black women e. Flu-like symptoms 25 to 34 years of age; 40% of HIV-infected in- 4. Bacterial causes of UTIs fants born to women unaware of HIV status a. E. Coli (most common) until after delivery b. Klebsiella 3. Transmission c. Proteus a. Sexual intercourse (80%) d. Neisseria gonorrhoeae b. IV drug use (19%) e. Pseudomonas c. Other (1%) 5. Diagnosis d. Mother to infant a. Symptoms (1) 15–25% if woman does not receive b. Urinalysis antiretroviral (ARV) therapy during c. Culture and sensitivity pregnancy d. If protein and WBC are present on urine (2) Less than 1% if woman receives multi- dipstick, consider culture agent ARV and if has undetectable e. Screen every 4 weeks in sickle cell trait, viral load at delivery diabetes, and previous pyelonephritis in 4. Diagnosis this pregnancy a. Risk assessment—drug use/sexual 6. Management histories a. Asymptomatic bacteriuria and UTI b. Universal screening of pregnant women (1) Treat with antibiotic even if no for HIV as part of routine prenatal tests symptoms with option to decline (opt-out screening) (2) Adequate fluids recommended (3) Cranberry juice c. Repeat screening in third trimester if high (4) Antimicrobial therapy risk, high incidence of HIV in reproductive (a) Ampicillin or amoxicillin age women in geographic area, signs or (b) Cephalosporins symptoms of acute HIV infection (c) Nitrofurantoin (contraindicated d. Rapid HIV testing at labor and delivery if in late third trimester and in status unknown (CDC, 2006) women with G-6-PD) e. HIV testing (d) Trimethoprim/sulfamethoxazole (1) Antibody testing (contraindicated in third trimes- (a) Screening tests—enzyme immu- ter or if have G-6-PD) noassay (EIA) or rapid test (5) Follow up 2 weeks later with a test of cure 112 Chapter 4 Pregnancy

(b) Confirmatory tests if screening (1) Viral load is strongest predictor for test is positive—Western blot or vertical transmission immunofluorescence assay (IFA) (2) Multi-agent ARV therapy during (2) Direct viral screens pregnancy—start after first trimester if (a) Nucleic acid testing if suspect mother does not need treatment acute retroviral syndrome or re- (3) Intravenous zidovudine therapy dur- cent infection ing labor and delivery (b) Confirm with subsequent an- (4) Avoid artificial rupture of membranes tibody testing to document if delivery is not imminent seroconversion (5) Consider C-section at 38 weeks if viral 5. Signs and symptoms of initial HIV infection load is greater than 1000 copies/ml a. Incubation period from exposure to clini- (6) Treat infant with ARV therapy—usual cal disease—days to weeks regimen is 6 weeks b. Acute viral illness syndrome—lasts 10 days h. Prevention of opportunistic infections or less i. Standard precautions for all blood and c. Fever body fluid-borne pathogens to include d. Night sweats blood, all body fluid secretions and ex- e. Fatigue cretions, nonintact skin and mucous f. Rash membranes g. Headache 8. Treatment—antepartum h. Lymphadenopathy a. Goals are treatment of maternal infec- i. Pharyngitis tion and reduction of risk for perinatal j. Myalgias transmission k. Arthralgias b. Highly active antiretroviral therapy l. Nausea (HAART) that includes: m. Vomiting (1) Two nucleoside analogues—zidovu- n. Diarrhea dine, didanosine, zalcitabine, lamivu- o. Becomes asymptomatic and chronic vire- dine and mia begins (2) Protease inhibitor—indinavir, riton- p. Time to immunodeficiency syndrome is avir, saquinavir or non-nucleoside 10 years analogue—nevirapine, delavirdine, 6. Signs and symptoms of AIDS efavirenz a. Generalized lymphadenopathy (3) Start after first trimester unless b. Oral hairy leukoplakia mother needs treatment c. Aphthous ulcers 9. Treatment—intrapartum d. Thrombocytopenia a. Zidovudine IV throughout labor and deliv- e. Opportunistic infections ery for vaginal birth f. Esophageal or pulmonary candidiasis b. Zidovudine IV starting 3 hours before g. Persistent herpes C-section and through delivery h. Cytomegalovirus 10. Counseling i. Molluscum contagiosum a. Pretest counseling is important j. Pneumocystis b. Informed consent k. Toxoplamosis c. Posttest counseling is also important 1. Neurologic disease—50% 11. Legal issues m. CD4+ count of less than 200 is definitive a. Confidentiality diagnosis b. Reporting 7. Management of HIV-positive women c. Partner notification a. Infection control d. Discrimination b. Initial evaluation 12. Concurrent disease concerns for HIV-infected c. Complete review of systems (ROS) women d. Physical examination a. Syphilis e. Initial labs—HIV antibody, CD4+ count, b. TB viral load c. HPV f. Follow-up by team of experts; interdisci- d. Hepatitis B plinary approach is most effective e. Pneumococcal infection g. Prevention of vertical transmission 13. Possible effects on pregnancy outcome Medical Complications 113

a. PROM e. Four cases of congenital rubella 2001– b. Preterm labor and birth 2004; three of these cases in women born c. Low birth weight outside US d. Fetal demise f. No reported cases of congenital rubella e. HIV transmission to fetus syndrome (CRS) since 2004 14. Fetal assessment as clinically indicated g. Risk of long-term complications from CRS a. US highest if mother infected in first trimester b. FMC h. Most common complications are deaf- c. Serial US as needed ness, IUGR, cataracts, retinopathy, patent d. NST with AFI, BPP ductus arteriosus 15. Intrapartum care 2. Pathophysiology a. Avoid invasive procedures a. Rubella is a single-stranded RNA virus b. Maintain universal body fluid precautions b. Acquired respiratory disease for all births c. Occurs 2–3 weeks following exposure c. Cleanse maternal secretions from baby as d. Infectious virus is present in respira- soon as possible tory tract 1 week prior to symptom d. Drain umbilical cord for cord blood/avoid development needles 3. Symptoms—rash e. Breastfeeding is not recommended—16% a. Discrete pink-red maculopapular rash probability of transmission of HIV infec- b. Appears first on face then trunk and tion to infant extremities f. Give emotional support c. May also have lymphadenopathy, fever, arthralgias • Toxoplasmosis d. Symptoms last 3 days 1. Incidence—15–40% of pregnant women have e. Up to 50% of all infections are subclinical antibodies to toxoplasmosis 4. Laboratory testing a. Primary infection in pregnancy is 1/1000 a. Demonstrate serologic conversion b. Most infections are asymptomatic b. Recent rubella infection will result in spe- c. Of those infected cific IgM in the fetal blood (1) 10% will have damage resulting in c. Can use CVS to recover virus lower IQ and deafness 5. Treatment—prevention (2) Severe congenital infection occurs a. No available antiviral therapy 1/10,000 b. Vaccination of susceptible reproductive (3) Infection can also cause abortion, pre- age women preconception or postpartum maturity, and IUGR c. No documented cases of CRS from vaccine 2. Diagnosis but recommend giving at least 4 weeks a. Laboratory data prior to attempting a pregnancy or post- b. Testing does not allow diagnosis between partum; may give while breastfeeding primary and secondary infection c. Testing for antitoxoplasma IgG antibody is • Varicella-zoster (VZV) difficult to interpret so not a practical test 1. Herpes virus causing two common infections to perform a. Varicella—chicken pox 3. Prevention (1) Primary infection is rare in pregnancy a. Fully cook meat (2) Greatest risk for congenital varicella b. Do not drink unpasteurized milk or cheese syndrome is when mother is infected c. Avoid kitty litter in first 20 weeks d. Good hand washing following gardening (3) Maternal infection occurring from 6 or wear gloves days before to 2 days after delivery can be passed to newborn causing serious • Rubella infection—5% mortality 1. Incidence (CDC, 2006) (4) Varicella infection causes varicella a. Rare in US pneumonia in 10–30% of adults b. Only 11 new cases of rubella (2006) b. Herpes zoster—shingles c. One half of new cases have occurred in (1) Secondary infection persons born outside US (2) Poses little risk to mother or baby d. 10–20% of reproductive women are susceptible to rubella 114 Chapter 4 Pregnancy

2. Incidence 4. Screening tests for tuberculosis a. Among pregnant women, 5/1000 a. Purified protein derivative (PPD) b. VZV is highly contagious and peaks in intradermally winter and spring (1) If negative, i.e., no induration, no fur- 3. Pathophysiology ther assessment is needed a. Respiratory inhalation of virus particles (2) Positive test interpreted by risk factors b. Results in a viremia (a) 5 mm is positive for very high c. Incubation period is 10–21 days, usually risk—HIV positive, with abnormal 14 days chest radiograph, recent contact d. Virus may be transmitted up to 2 days with active case prior to rash (b) 10 mm is positive for high risk, 4. Diagnosis i.e., foreign born, HIV nega- a. Prior to rash, adults experience fever, mal- tive IV drug user, low-income aise, myalgias, and headache populations, associated medical b. Rash—maculopapular rash that becomes problems vesicles (c) 15 mm is positive for those with c. New vesicles continue for 3–4 days none of these risks d. Crusted by 1 week (3) Vaccination with bacillus Calmette- 5. Complications Guerin (BCG) requires special guid- a. Pneumonia ance for interpretation b. Increased risk of preterm labor and birth 5. Signs and symptoms 6. Treatment a. Cough with minimal sputum production a. Antiviral agent—IV acyclovir for severe b. Low-grade fever infection in woman c. Hemoptysis b. Infection in mother 6 days before deliv- d. Weight loss ery—give VZIG, prepare for tocolysis to 6. Diagnosis delay delivery, give VZIG to infant a. Chest radiograph c. Infection in mother within 3 days postpar- b. Sputum for acid fast bacillus tum—give infant VZIG c. Extrapulmonary disease occurs in any or- 7. Prevention gan; disseminated disease exists in 40% of a. Varicella vaccination for all susceptible HIV-positive patients reproductive age women preconception 7. Treatment (CDC, 2008) (at least 4 weeks before attempting preg- a. Initiate treatment of pregnant women nancy) or postpartum when probability of TB is moderate to high b. Varicella-zoster immunoglobulin (VZIG) (1) Recent PPD converters—incidence of as early as possible if pregnant woman ex- active infection is 3% the first year posed and susceptible (2) PPD positive through exposure to active disease because infection is 0.5% • Tuberculosis (TB) per year 1. Definition—infection, mostly in the lung, by (3) HIV-positive women have annual ac- Mycobacterium tuberculosis; clinical disease tive disease risk of 8% occurs in 10% of those infected b. Latent TB infection 2. Populations at risk for tuberculosis (1) Isoniazid daily or twice weekly for 9 a. HIV-infected women months

b. Foreign-born women from countries with (2) Vitamin B6 (pyridoxine) 50 mg daily high TB prevalence during treatment c. Medically underserved low-income c. Active tuberculosis in pregnancy populations (1) Isoniazid, rifampin, and ethambutol d. Close contacts of persons with active daily for 2 months infection (2) After initial 2 months of treatment, e. Alcoholics and IV drug users Isoniazid and rifampin daily or twice 3. Incidence (CDC, 2008) weekly for 7 months a. 13,299 new cases in US (2007); 4.4 per (3) Pyridoxine 50 mg daily throughout 100,000 persons treatment b. Foreign-born persons accounted for 58% d. HIV-infected pregnant woman with sus- of new cases pected TB—consult with infectious disease specialist Medical Complications 115

e. Breastfeeding is not contraindicated with (a) May prefer if high prevalence of TB treatment GDM in patient population f. Precautions (b) 100 g OGTT (1) Liver toxicity 5. Diagnostic criteria for GDM—presence of (2) Drug resistance at least two of the following plasma glucose values • Diabetes a. Fasting 95 mg/dl or greater 1. Definition—endocrine disorder of abnormal b. 1 hour 180 mg/dl or greater carbohydrate metabolism resulting in inad- c. 2 hour 155 mg/dl or greater equate production and/or utilization of insulin d. 3 hour 140 mg/dl or greater 2. Gestational diabetes 6. Presence of three or more of the following a. Occurs in 2–12% of pregnancies. risk factors increases the chance of perinatal b. Results from the diabetogenic effect of mortality: pregnancy a. Uncontrolled hyperglycemia c. hPL (human placental lactogen) acts as an b. Ketonuria, nausea, vomiting insulin antagonist c. PIH, edema, proteinuria d. Estrogen and progesterone may also act as d. Pyelonephritis insulin antagonists e. Lack of compliance with care 3. Diagnosis f. Maternal age older than 35 years a. Risk assessment at initial prenatal visit 7. Management—objective is to maintain strict b. High risk (American Diabetes Association, levels of maternal glucose for optimum peri- 2009) natal outcomes (1) Obesity a. Comanage or transfer to perinatal center (2) Prior history of GDM or large for ges- b. Diet tational age infant (1) 30 kcal/kg of actual or ideal body (3) Presence of glycosuria weight (4) Diagnosis of PCOS (2) 25% at breakfast (5) Strong family history of type 2 (3) 30% at lunch diabetes (4) 30% at dinner c. Low risk (American Diabetes Association, (5) 15% at snack 2009) c. Distribution of calories (1) Age of younger than 25 years (1) Protein 20% of calories (2) Normal weight before pregnancy (2) Fat 30–35% of calories (3) Member of ethnic group with low (3) Carbohydrates 45–50% of calories prevalence of diabetes d. Medications (4) No known diabetes in first-degree (1) Oral hypogylcemics—glyburide and relatives acarbose are pregnancy category B; (5) No history of abnormal glucose others are category C tolerance (2) Insulin (6) No history of poor obstetrical e. Maternal monitoring outcome (1) PIH 4. Screening (American Diabetes Association, (2) Changing insulin requirements 2009) (3) Decreased need in first trimester due a. High risk—screen as soon as possible us- to low hPL levels ing standard diagnostic testing (4) Increases in second trimester due to b. All women not considered low risk— increasing hPL levels

screen at 24–28 weeks (5) HgbA1C/fasting plasma (1) Two-step approach f. Fetal monitoring (a) One-hour 50 g glucose challenge (1) Increased risk of neural tube defects test (GCT) and cardiac anomalies in nongesta- (b) If 130 mg/dl (90% sensitivity) or tional diabetics more, or greater than 140 mg/dl (2) Ultrasound for IUGR, macrosomia, (80% sensitivity), perform diag- polyhydramnios nostic 100 g OGTT on another day (3) FMCs beginning at 28 weeks (2) One-step approach (4) NSTs with AFI or CST beginning at 36 weeks 116 Chapter 4 Pregnancy

(5) May consider amniocentesis for L/S c. African Americans approximately 5–8% ratio (maturity is 3:1 with positive pg) d. American Hispanics approximately 5–10% g. Immediate postpartum—monitor insu- 2. Types lin requirements (usually decrease 24–48 a. ABO incompatibility hours after delivery of the placenta) (1) 20–25% of pregnancies are ABO h. 6–12 weeks postpartum—screen for dia- incompatible betes and then follow with subsequent (2) Isoimmunization causes 60% of fetal screening for diabetes or prediabetes hemolytic disease b. Maternal serum contains anti-A or anti-B • Thyroid disease (1) Rarely causes more than fetal anemia 1. Definition—most common thyroid diseases in with mild to moderate hyperbiliru- pregnancy are nontoxic goiter, hyperthyroid- binemia in the first 24 hours of life ism, hypothyroidism, and thyroiditis (2) Due to the fact that the IgM anti-B or 2. Impact of pregnancy on maternal thyroid IgM anti-A cross the placenta poorly physiology is great; structural and functional c. Sensitization caused by minor antigens changes related to pregnancy can cause confu- (1) Some cause hemolytic disease, some sion in defining abnormalities do not 3. Thyroid enlarges somewhat due to hyperplasia (2) Believed to be the result of incompat- and increased vascularity but does not cause ible transfusion although may be seen serious thyromegaly in multiparas 4. Thyroid hormones in pregnancy— total serum d. Kell—may have mild to severe with hy-

thyroxine (TT4) and triiodothyronine (TT3) drops (K-kills) concentrations increase; TSH and free thyrox- e. Duffy—Fya may have mild to severe b ine (FT4) levels are not affected with hydrops; Fy —not associated with 5. Thyrotoxicosis or hyperthyroidism problems a. Incidence—1/2000 pregnancies 3. Pathogenesis for Rh isoimmunization b. Signs and symptoms a. Three requirements (1) Tachycardia, more than normal in (1) Fetus must be D+ and mother D– pregnancy (2) Mother must be able to be sensitized (2) Elevated sleeping pulse rate (3) Fetal cells must gain access into the (3) Thyromegaly mother’s blood stream in sufficient (4) Exophthalmos quantities (5) Failure to gain weight with normal or b. Occurs when increased food consumption (1) There is a transfusion of incompatible c. Diagnosis blood to the mother, usually before

(1) Elevated serum free thyroxine (FT4) or pregnancy free thyroxine index (FTI) levels (2) A feto-maternal exchange of blood (2) Suppressed TSH levels during d. Treatment (a) Delivery (1) Control with thioamide drugs; propyl- (b) Spontaneous or induced abor- thiouracil or methimazole tion (woman may not realize she’s (2) Thyroidectomy if medical approach pregnant) unsuccessful but easier done out- (c) Amniocentesis side of pregnancy due to increased (d) Ectopic vascularity (e) Placental separation e. Maternal and fetal outcomes (f) Unknown cause (1) Good if treatment successful 4. Implications (2) If not, higher incidence of preeclamp- a. Maternal sia and heart failure as well as preterm (1) No significant maternal complications birth, IUGR and stillbirth (2) Fetal loss b. Fetal • Blood incompatibilities—D(Rh) isoimmunization (1) Mother produces anti-D antibodies 1. Incidence (Rh2) (IgG), which cross the placenta a. Highest incidence found in Basques of (2) Hemolysis of fetal RBC then occurs France and Spain (25–40%) (3) Fetal anemia results with hematopoi- b. White Americans approximately 15% esis in liver and spleen Medical Complications 117

(4) Fetal liver and spleen enlarge (3) Serum iron-binding capacity elevated (5) Liver and spleen show degenerative (but not a significant finding since it changes. is elevated in pregnancy in absence of (6) Erythroblastosis fetalis results (ascites, iron deficiency) cardiac failure, hydrothorax) f. Associated with low birth weight, prema- (7) Hydrops fetalis with generalized ture delivery, perinatal mortality edema g. Management and treatment—correct the c. Newborn hemoglobin mass deficit and rebuild iron (1) Maternal IgG is still present and at- stores tacking RBC (1) Iron replacement therapy (2) Further RBC breakdown occurs (2) Ferrous sulfate, ferrous gluconate, fer- (3) Fetal liver is immature and unable to rous fumarate clear RBC (3) Include vitamin C and folic acid (4) Hyperbilirubinemia results (4) Intramuscular therapy if unable to (5) Bilirubin causes kernicterus with CNS take orally or if severely anemic damage and possible death (5) Iron therapy for 3 months after ane- 5. Management mia corrected a. Unsensitized pregnancy—mother Rh 2. Anemia from acute blood loss negative with negative antibody titer a. Definition—drop in hemoglobin due to (1) ABO/D group and antibody titer at moderate-to-severe blood loss, which can first visit occur at any time in pregnancy (2) Repeat antibody screen at 28 b. Etiology—abortion, ectopic pregnancy, weeks and give RhoGAM if remains hydatidiform mole, placenta previa, unsensitized abruptio placenta, placenta implantation (3) RhoGAM is protective for 12 weeks anomalies, etc. (4) If infant is Rh positive, give mother c. Management and treatment RhoGAM again after delivery (1) Massive hemorrhage requires restora- b. Sensitized pregnancy—mother Rh nega- tion of volume and cells to maintain tive with positive antibody titer (> 1:4) perfusion of vital organs (1) Consult—comanage or transfer care (2) Treat residual iron depletion (Hb (2) Follow fetus with serial ultrasounds to 7 g/dL or greater) with oral iron for assess for signs of ascites 3 months as long as woman is afebrile (3) Follow titers to assess need for and able to ambulate amniocentesis 3. Megaloblastic anemia a. Definition—group of hematologic dis- • Acquired anemias orders characterized by blood and bone 1. Iron deficiency anemia marrow abnormalities caused by impaired a. Definition—hemoglobin less than 11.0 g/ DNA synthesis dL first trimester, 10.5 g/dL second tri- b. Prevalence—rare in the US mester, 11.0 mg/dL third trimester and c. Etiology—in the US, during pregnancy, postpartum most always results from folic acid de- b. Etiology—related to poor nutrition re- ficiency due to lack of consumption of sulting in inadequate iron stores; conse- green leafy vegetables, legumes, and ani- quence of expansion of blood volume with mal protein inadequate expansion of maternal hemo- d. Signs and symptoms—nausea, vomiting, globin mass and anorexia, which worsen as deficiency c. Signs and symptoms—not apparent un- increases less severely anemic e. Diagnosis—laboratory tests showing d. Differential diagnosis hypersegmentation of neutrophils, mac- (1) Anemia associated with chronic rocytic erythrocytes, bone marrow mega- disease loblastic erythropoiesis (2) Blood loss effect f. Risks to fetus—neural tube defects e. Diagnostic tests g. Prevention—folic acid (0.4 mg daily for (1) Serum ferritin levels lower than childbearing-aged women; 4 mg daily normal prior to and during pregnancy for women (2) Microcytic, hypochromic erythrocytes with history of previous neural tube defect infant), nutritious diet, and iron 118 Chapter 4 Pregnancy

• Inherited anemias—hemoglobinopathies b. Displacement of the appendix by the 1. Sickle cell hemoglobinopathies growing uterus moves the point of a. Sickle cell anemia (SS disease) pain and tenderness associated with b. Sickle cell–hemoglobin C disease appendicitis (SC disease) c. Leukocytosis, to some extent, occurs in c. Sickle cell–b-thalassemia disease pregnancy (S–b-thalassemia disease) d. Confounding diagnosis, especially in 2. Etiology—individual inherits a gene for pregnancy; pyelonephritis, renal colic, S hemoglobin from each parent, or an S and a placental abruption, and degeneration of C gene from each, or an S and b-thalassemia a myoma gene from each e. In late pregnancy, symptoms may be very 3. Incidence atypical a. SS disease—1 in 12 African Americans has 3. Diagnosis and management sickle cell trait—SA hemoglobin; incidence a. Persistent abdominal pain and tenderness is 1 in 576 theoretically but is, in fact, less is most critical symptom common b. Immediate surgical exploration indicated b. SC disease—1 in 40 African Americans if suspected has hemoglobin C gene; incidence of SC c. Diagnosis correct in 50–65% of cases; disease in African-American pregnant verify to prevent peritonitis women is 1 in 2000 c. Sickle cell-b-thalassemia disease—1 in • Neoplastic disease 2000 African-American women 1. Incidence of cancer in pregnancy—uncom- 4. Signs and symptoms—SS is worst of hemoglo- mon; second leading cause of death in women binopathies in pregnancy ages 15–44 in US a. Sickle cell crisis occurs more frequently in 2. Most frequent types of cancers in pregnancy— pregnancy genital tract, breast, and malignant melanoma b. Infections and pulmonary complications 3. Principle of treatment—the woman should not more common be penalized for being pregnant c. Contributes to maternal mortality 4. Approach to the pregnant woman with cancer 5. Differential diagnosis a. Surgical intervention for diagnosis, staging a. Thalassemia or therapeutic purposes is well tolerated; b. G-6-PD deficiency oophorectomy may be done after 8 weeks 6. Physical findings of gestation since placental hormone pro- a. Hb 7 g/dL or less duction is sufficient b. Intense pain of crisis particularly in third b. Radiation of 15–20 rads may cause mi- trimester, in labor, and in puerperium crocephaly and mental retardation in the c. Fever due to dehydration or infection fetus d. Acute chest syndrome—pleuritic pain, c. Chemotherapy risk for the fetus depends cough, fever, lung infiltrate, and hypoxia on GA, but avoid at 5–10 weeks if possible 7. Management and treatment 5. Breast cancer a. Consult and comanage a. Incidence—most common malignancy b. Weekly fetal surveillance after 32–34 weeks at all ages; estimated at 10–30/100,000 c. Pain medication pregnancies d. Follow-up (including possible need for b. Effects of pregnancy on breast cancer; paternal blood screening and genetic none of note; stage of the disease at time counseling) of diagnosis and treatment more impor- e. Counseling for current and future tant to survival pregnancies c. Diagnosis—same as for nonpregnant women; any suspicious breast mass • Appendicitis should be diagnosed immediately using 1. Incidence—suspected in 1/1000; found in one or more of the following methods: 1/1500 pregnant woman; most common rea- (1) Needle aspiration can differentiate a son for surgical exploration during pregnancy cyst or galactocele from solid tumor 2. Pregnancy confounds signs and symptoms of (2) Tissue biopsy if needle biopsy results appendicitis are not diagnostic a. Nausea, vomiting, and anorexia of preg- (3) Mammography—but more diffi- nancy vs appendicitis cult due to denser tissue; requires Medical Complications 119

adequate shielding; radiation is less in latter half, can wait for fetal viability than 100 mrad and maturation (4) Once cancer diagnosis made, limited metastatic search and chest radio- • Heart disease gram done; computerized tomog- 1. Incidence—rheumatic heart disease almost raphy (CAT) bone and liver scans nonexistent in US due to better management are contraindicated due to ionizing and resources; congenital heart disease ac- radiation counts for half of pregnancy heart problems d. Treatment 2. Heart disease accounts for 5–15% of maternal (1) Surgery as soon as the diagnosis is deaths confirmed 3. Etiology—cardiac output increases in preg- (2) Radiotherapy not recommended nancy by 30–50%, half of which occurs by (3) Chemotherapy can be given in the eighth week; reaches maximum level by pregnancy midpregnancy e. Recommendations for future pregnan- 4. Symptoms cies—little evidence exists to say that a. Progressive dyspnea survival is adversely affected by pregnancy b. Nocturnal cough after mastectomy for breast cancer c. Hemoptysis 6. Malignant melanoma d. Syncope a. Incidence—estimated at 0.14 to 2.8 per e. Chest pain 1000 live births 5. Clinical findings b. Skin changes to watch and report—pig- a. Cyanosis mented lesion that changes b. Clubbing of fingers (1) Contour c. Neck vein distension (2) Surface elevation d. Systolic murmur grade 3/6 or greater (3) Discoloration e. Diastolic murmur (4) Itching f. Cardiomegaly (5) Bleeding g. Persistent arrhythmia (6) Ulceration h. Persistent split-second sound c. Clinical stages 6. Diagnosis—normal changes of pregnancy (1) Stage I—no positive lymph nodes make diagnosis difficult (85%); tumor thickness is single most a. EKG important factor in predicting survival b. Echocardiography at this stage c. Chest radiograph (2) Stage II—nodes are positive 7. Functional classification of cardiac disease— (3) Stage III—distant metastases based on past and present disability, uninflu- d. Effect of pregnancy—usually have thicker enced by physical signs tumors when diagnosed in pregnancy a. Class I—uncompromised; no limit on e. Treatment—surgery and chemotherapy if activity; no symptoms of cardiac insuffi- indicated ciency, no anginal pain 7. Cervical cancer b. Class II—slightly compromised; ordinary a. Incidence—most common form of cancer activity results in excessive fatigue, palpi- in pregnancy—carcinoma in situ 1.3/1000; tation, dyspnea, or anginal pain invasive carcinoma 1/2200 pregnancies c. Class III—markedly compromised; b. Abnormal Pap tests equal 3% during marked limitation of activity; less than pregnancy normal activity causes symptoms mani- c. Colposcopy to confirm and identify fested in Class II lesions d. Class IV—severely compromised; symp- d. Treatment—varies with stage of cancer toms manifested in Class II and III develop and duration of pregnancy at rest and become more intense with (1) Microinvasive disease follows same activity guidelines as for nonpregnant intra- 8. Antepartum management of the patient with epithelial disease; continuation of Class I and Class II cardiac disease with regard pregnancy and vaginal delivery with to the following: postpartum therapy a. Preventative measures—avoid URI con- (2) Invasive cancer is treated immediately tact; provide pneumococcal and flu in first half of pregnancy; if detected vaccines 120 Chapter 4 Pregnancy

b. No smoking 6. The vessels of the umbilical cord are: c. No illicit drugs, especially cocaine and a. One vein with oxygenated blood and two amphetamines arteries with deoxygenated blood d. Instruct client regarding signs and symp- b. One vein with deoxygenated blood and toms of developing congestive heart two arteries with oxygenated blood failure: c. Two veins with oxygenated blood and one (1) Nocturnal cough artery with deoxygenated blood (2) Basilar rales d. Two veins with deoxygenated blood and one artery with oxygenated blood I want to give special thanks to Annie Gibeau, CNM, MS, a faculty colleague of the NYU Midwifery Program, 7. The uterus is palpable at the symphysis pubis at: for all that she contributed to the development of this a. 6 weeks chapter. b. 8 weeks c. 12 weeks Â Questions d. 16 weeks Select the best answer. 8. Implantation occurs ______after fertilization.

1. M. S. comes to the office indicating her period a. 24–48 hours is 1 month overdue. Her level of pregnancy b. 3–4 days diagnosis is? c. 6–7 days d 9–10 days a. Positive b. Presumptive 9. Placental transport of substances occurs by: c. Possible a. Simple perfusion d. Probable b. Facilitated diffusion 2. R. L. states she is trying to get pregnant and c. Active osmosis had unprotected intercourse on day 14 of d. Active perfusion her usual 28-day menstrual cycle. However, 10. The human zygote consists of: the pregnancy test was negative 3 days later. Appropriate management would be to: a. 46 chromosomes from each parent b. 2 pairs of sex chromosomes a. Order an ultrasound c. 23 chromosomes b. Prescribe progesterone d. 23 pairs of chromosomes c. Repeat the test in a week d. Order a serum pregnancy test 11. The trophoblast will ultimately become the: 3. Pregnancy tests detect: a. Placenta b. Embryo a. Estrogen c. Blastocyst b. Human chorionic gonadotropin d. Umbilical cord c. Human placental lactogen d. Progesterone 12. M. R. presents for an antepartal visit at 26 weeks and wants to know how big the fetus 4. During the first few weeks of pregnancy, pro- is. Your response would be that the fetus is gesterone is secreted by the: approximately: a. Placenta a. 0.5 lb b. Corpus luteum b. 1 lb c. Endometrium c. 2 lb d. Trophoblasts d. 4 lb 5. Blood in the chorionic villi pertains to whose 13. At her initial visit, M. R. was a healthy primi- circulation? gravida, but you heard a Grade I systolic a. Mother murmur. Your management would be: b. Mother and fetus a. A cardiology consult c. Placenta b. Chest radiograph d. Fetus c. Immediate referral d. No intervention Questions 121

14. The drop in diastolic blood pressure during 20. P. J. has had three spontaneous abortions and normal pregnancy is partly the result of: is now pregnant for the fourth time. The term that defines her status is: a. Plasma volume expansion b. Progesterone’s effect on vessel walls a. Multipara c. Increased cardiac output b. Nullipara d. Pooling of plasma in tissues c. Primigravida d. Primipara 15. Changes in the respiratory system due to pregnancy may cause: 21. The calculation of estimated date of birth (EDB) by Naegele’s rule is based on: a. Tachypnea b. Cough a. A 28-day menstrual cycle c. Increased chest diameter b. Average length of pregnancy of 290 days d. Pale nasal mucosa c. 32-day cycle d. Length of pregnancy of 270 days 16. C. D., a primigravida, came in for a visit at 34 weeks stating she has “a lot of vaginal dis- 22. A. B. is pregnant for the third time. Her charge,” but no other problems. On exam you obstetrical history indicates she has had two see a white, odorless discharge of moderate miscarriages and one twin birth at 36 weeks. quantity. Your next step would be: One twin died but the other is alive and well. The four-digit descriptor of this history is: a. Treat for candida b. Check for trichomoniasis a. 0121 c. Reassure that this is normal b. 0221 d. Send a vaginal culture c. 2021 d. 2201 17. R. P. comes for a 24-week visit and mentions that her interest in sex has increased greatly. 23. D. M. comes for her first antepartal visit. When You respond to her concern because you know asked the date of her last menstrual period, that increased libido is: she indicates she has not had one since she has been nursing her 6-month-old daughter. You a. A normal variation of response in diagnose that she is pregnant. How would you pregnancy determine estimated date of birth (EDB)? b. An abnormal response of changing image c. Reflective of repressed desire to disrupt the a. Determine when she expected to get her pregnancy period and calculate from there d. The early sign of a parenting disorder b. Document quickening and extrapolate from there 18. R. Q., at her 36-week visit, tells you that she is c. Send her to fetal assessment unit for an having nightmares that include labor as well ultrasound as fears of having an abnormal baby. Your best d. Get good sexual history and use last coitus response is: as the basis for calculation a. Tell her there is nothing to worry about, as 24. R. P., G1 P0, comes for her 20-week visit. Her most babies are fine abdominal exam shows the uterine fundus to b. Encourage her to tell you more about the be half way between the symphysis and the nightmares and her fears umbilicus. This finding leads you to consider: c. Make her an appointment with a mental health nurse practitioner a. Intrauterine growth restriction (IUGR) d. Reassure her that there are dangers about b. Nothing, since it is normal which we all have to worry c. Oligohydramnios d. She is not eating and gaining enough 19. Initial management of constipation in preg- weight nancy should include suggestions for: 25. In your abdominal exam using Leopold’s a. Increased protein intake maneuvers, the first step is to determine fetal: b. Limitation of calcium rich foods c. Use of a laxative a. Attitude d. Increased intake of fiber and fluids b. Position c. Engagement d. Lie 122 Chapter 4 Pregnancy

26. D. P. presents for her first antepartal visit. She is a. At the first visit 9 weeks pregnant and requests that you listen b. When labor starts for the FHT. Your response would be: c. At 20 weeks d. At 35–37 weeks a. “No, there’s no reason to since it can’t be heard yet anyway.” 33. The triple screen tests for: b. “Sure, I’ll listen but we may not hear it a. AFP, progesterone, hCG yet.” b. AFP, estriol, hCG c. “Sure we can listen since it’ll be there c. Estriol, progesterone, hPL now.” d. Estradiol, progesterone, AFP d. “We don’t usually do that at this visit.” 34. A nonstress test containing 2 fetal heart accel- 27. Normal findings on speculum and pelvic exami- erations lasting 15 seconds that are 15 beats nation of a pregnant woman include: per minute above the baseline is: a. Eversion of the squamocolumnar junction a. Negative b. Pale vaginal mucosa b. Positive c. Open cervical os c. Nonreactive d. Firm, slightly enlarged cervix d. Reactive 28. Clinical pelvimetry of a woman with an 35. The recommended folic acid supplement for adequate pelvis would provide which of the a woman with a past history of a baby with a following findings? neural tube defect is: a. Ischial tuberosities of 10 cm and a flat a. 4 mg per day starting before conception sacrum b. 0.4 mg per day starting with a missed b. Convergent sidewalls period c. Pubic arch of 90 degrees with diagonal con- c. 2 mg per day prior to conception jugate of greater than 11.5 cm d. 0.4 mg per day throughout pregnancy d. Protuberant ischial spines 36. B. D. comes for her first antepartal visit. She is 29. The value of clinical pelvimetry rests in its 5 ft 4 in and weighs 190 lb (BMI 33). Weight ability to: goal for the pregnancy should be: a. Predict successful vaginal birth a. Maintain current weight b. Identify the characteristics of the woman’s b. Gain 11–20 lb pelvis c. Gain 25–35 lb c. Determine if she will have a breech d. Lose 10–15 lb presentation d. Predict an occiput posterior position 37. Exercise guidelines for healthy pregnant women include suggestions to: 30. F. R., a primigravida at 16 weeks, states that she is concerned because she has not felt the baby a. Discontinue exercise at 20 weeks move yet. Your response should be: b. Begin intense program of exercise, especially if prepregnant weight was high a. “Most women with a first pregnancy don’t c. Modify the existing program if symptoms feel movement until around 20 weeks.” occur b. “You’re worrying too much, just relax.” d. Limit fluids before exercising c. “I’ll order an ultrasound, just to be sure everything is fine.” 38. Anticipatory guidance concerning sexual d. “I’d like you to return in a week so we can activity during pregnancy includes: recheck it.” a. Sexual intercourse may continue until 31. Maternal serum alphafetoprotein screening is early third trimester in an uncomplicated performed in what time frame? pregnancy. b. Sexual intercourse is contraindicated a. 8–12 weeks throughout pregnancy if there is a past b. 12–15 weeks history of preterm labor. c. 15–19 weeks c. The pregnant woman’s sexual desire may d. 20–24 weeks change throughout pregnancy. 32. CDC recommends screening for group B strep- d. Most pregnant women do not desire sex tococcus (GBS) at what point? after the first trimester. Questions 123

39. Breastfeeding should be encouraged for: c. Routine screening early in pregnancy and at 24–28 weeks a. All women whose families strongly support d. The same as for the normal weight woman the idea b. All pregnant women who are not HIV 46. G. H. comes for her 34-week visit, at which time positive the fundus measures 39 cm. Abdominal palpa- c. Those with adequate breast tissue tion reveals a large uterus and difficulty feeling d. Women who desire to do so fetal parts. The most likely diagnosis is: 40. M. D. comes for her first antepartal visit at a. Multiple gestation 8 weeks and tells you she has nausea every b. Macrosomic fetus morning, but is able to eat and drink in the c. Uterine fibroid afternoon. Your management at this point d. Polyhydramnios would include: 47. W. T., during her initial prenatal visit, mentions a. Prescription for antinausea medicine that she had a rubella immunization 3 weeks

b. Vitamin B6 50 mg bid before conceiving this baby. Your plan is to: c. Small frequent meals a. Advise her to consider termination of the d. Carbonated beverage on rising pregnancy 41. The fatigue of early pregnancy is best managed b. Continue regular care by: c. Consult with an infectious disease specialist d. Referral to perinatologist a. Ruling out a thyroid problem b. Encouraging increased exercise 48. On physical examination at an initial prenatal c. Increased amounts of caffeinated drinks visit of a 25-year-old woman who is at 14 d. Reassurance and rest weeks’ gestation, you feel a 1 cm mobile, nontender mass in the upper, outer quadrant 42. Leg cramps may be relieved by: of her right breast. Your plan is: a. Pointing the toes a. Explain this is normal with hormonal b. Hot compresses changes of pregnancy c. Flexion of the foot b. Advise her you will watch at each visit to d. Hot tub baths assess for any change 43. R. T. comes for her 36-week visit, during which c. Schedule a mammogram to be done in the she mentions that her hands and feet are some- third trimester what swollen. She has gained 2 lb since her visit d. Refer for further evaluation with biopsy 2 weeks ago; her BP is 128/76 and she has no 49. A pregnant woman who is 5 ft 3 in in height protein in her urine. What is your plan? has a prepregnancy weight of 115 lb. Which of a. Refer to perinatologist for impending the following represents the most appropriate preeclampsia weight for her by the end of her pregnancy? b. Explain the edema at this stage is normal a. 125 lb and see her in a week b. 135 lb c. Order bed rest with return visit in a week c. 145 lb d. Restrict salt and fluid intake d. 155 lb 44. T. G. asks about the value of childbirth prepara- 50. The biophysical profile (BPP) assesses fetal well- tion classes during a second trimester visit. You being with: tell her that the evidence indicates that they are associated with: a. A combination of nonstress test and ultrasound evaluation to assess five variables a. Reduced use of analgesics/anesthesia b. Both a contraction stress test and ultra- during labor sound evaluation of amniotic fluid volume b. Improved parenting skills c. Serial ultrasounds to evaluate amniotic c. Decreased Cesarean rates fluid volume as well as fetal breathing and d. Less use of IVs in labor body movement and tone 45. Diabetes screening recommendations during d. Evaluation of fetal movement with kick pregnancy for the woman who is obese include: counts after administration of oxytocin or nipple stimulation a. Fasting blood glucose each trimester

b. Testing Hemoglobin A1C in the first trimester 124 Chapter 4 Pregnancy

51. An appropriate plan of care for a 40-week c. Tell her to get more rest and her interest gestation woman with a BPP score of 8 that will increase includes a 2 score for amniotic fluid volume d. Get her to talk about what she’s feeling includes: and thinking about sex a. Order a contraction stress test 57. The screening test for group B streptococcus b. Repeat the BPP in 48 hours requires that the specimen be obtained from c. Schedule a return visit after 1 week the: d. Admit for induction of labor and delivery a. Ectocervix and vaginal side walls 52. Evaluation of fetal lung maturity is a required b. Ectocervix and endocervical os procedure for a: c. Endocervical os and rectum d. Vaginal introitus and rectum a. Scheduled delivery before 39 weeks’ gestational age 58. Pregnancy loss and the woman’s need for b. Scheduled delivery before 37 weeks’ gesta- appropriate grieving occur across the reproduc- tional age tive spectrum. Maladaptive grief reactions are c. Laboring woman at 37 weeks’ gestational best addressed by: age a. Telling her to put the baby’s things away d. Laboring woman at 35 weeks’ gestational b. Listening to whatever the woman has to age say 53. W. M., who is 11 weeks pregnant, calls you c. Encouraging her to be strong so she’ll get from the ER to say she sustained a laceration, past it and they want to give her a tetanus booster. d. Making her an appointment with a You would tell her: therapist a. All vaccinations are contraindicated in 59. Recommended routine screening tests at an pregnancy initial antenatal visit during the first trimester b. It is not a problem because she doesn’t include: need it a. Group B streptococcus culture c. It can be given in pregnancy if needed b. Syphilis serology d. She should wait until the third trimester c. Triple marker screen 54. Drugs from which one of the following catego- d. Ultrasound ries may be given to a pregnant woman when 60. Which of the following statements concerning the potential benefit justifies the potential influenza vaccination for pregnant women is fetal risk: correct? a. Category A a. Vaccination is recommended for all women b. Category B who will be pregnant during the influenza c. Category C season. d. Category X b. Pregnant women with HIV infection should 55. A woman who is pregnant for the second time, not receive this vaccination. and her first pregnancy ended with a sponta- c. The pregnant woman should be offered neous abortion at 10 weeks is a: the option of either the injection or nasal administration of the vaccine. a. Multigravida d. Vaccination should be given only in the b. Multipara second or third trimester. c. Primigravida d. Primipara 61. RDA of calories and protein during pregnancy is: 56. A pregnant woman presents for her 24-week visit, at which time she relates that she doesn’t a. 3,000 kcal and 50 g/day feel very interested in sex anymore. Your b. 3,500 kcal and 60 g/day response is to: c. 3,800 kcal and 60 g/day d. 2,500 kcal and 60 g/day a. Tell her this is common and she should not be concerned 62. R. H. presents for her 36-week visit. Abdominal b. Assure her the interest will return in the exam reveals a likelihood of polyhydramnios. third trimester Questions 125

In response to her question of where does the c. CBC or hematocrit fluid come from, you answer: d. Multiple marker screen a. From the mother’s blood volume 69. R. D. at 37 weeks calls to say she feels like the b. Through a combination of maternal serum fetus is moving less. After further inquiry you and fetal urination decide to send her for an NST. She asks what c. Produced by amniotic epithelium and fetal this is. You explain that it is an assessment of functions fetal well-being based on: d. From fluid ingested by mother a. Evaluation of body movements 63. D. B., a 24-year-old primigravida, during her b. Breathing movements initial visit asks how the fetus has genes from c. Fetal heart-rate response to fetal both her husband and herself. Your response is movement based on what fact? d. Fetal body tone a. Mitosis occurs producing half the number 70. P. R. comes for a first visit at 11 weeks’ gesta- of chromosomes. tion. Her history reveals her concern about sore b. Meiosis occurs producing half the number gums that sometimes bleed. Your thinking is: of chromosomes. a. She most likely needs to see a periodontist. c. The egg is a somatic cell. b. Gingivitis is common in pregnancy with d. Sperm is a somatic cell. increased vascularity of connective tissue. 64. Which of the following are parts of the c. She should be started on antibiotics to placenta? prevent systemic infection. d. She should be placed on a soft diet until a. Trophoblast, chorion, amnion the problem is resolved. b. Trophoblast, chorion, endometrium c. Chorion, amnion, umbilical cord 71. A woman presents at 32 weeks’ gestation with d. Intervillous spaces, endometrium, vaginal bleeding for the past 6 hours, back trophoblast pain, and irregular abdominal cramping pain. Exam reveals diffuse abdominal tenderness and 65. The term conceptus means: increased uterine tone. You suspect: a. The embryo and placenta a. Marginal placenta previa b. The embryo and membranes b. Placental abruption c. The embryo, membranes, and placenta c. Preterm labor d. The embryo, membranes, placenta, and d. Pyelonephritis endometrium 72. A postterm pregnancy is best diagnosed by: 66. What structure in human reproduction produces the most diverse and greatest quantity of a. Certain LMP steroid and protein hormones? b. Third trimester ultrasound c. Fundal growth a. Trophoblast d. Quickening b. Blastocyst c. Chorion laeve 73. Serial beta hCG levels are done after uterine d. Deciduas basalis evacuation for hydatidiform mole to: 67. At her 32-week visit, B. R. asks you to tell her a. Assure that the woman is not pregnant in what you are looking for or feeling when doing the first year after treatment her abdominal exam with Leopold’s maneuvers. b. Monitor for persistent trophoblastic You respond that you are: proliferation c. Identify a pregnancy early so appropriate a. Determining the placement of the placenta care can be provided b. Finding what direction the fetus is lying d. Assess for a possible undetected ectopic c. Evaluating the size of the uterus pregnancy d. Evaluating adequacy of fetal growth 74. P. R. indicates she is afraid of pitocin because 68. T. D. comes for an 18-week visit. Appropriate her sister had a uterine rupture when she was routine screening tests at this visit include: induced. Your response would be: a. Gestational diabetes testing b. Chlamydia and gonorrhea tests 126 Chapter 4 Pregnancy

a. Reassurance since she won’t need induction 80. The fetal system most associated with oligohy- anyway dramnios is the: b. Discuss how pitocin is given with assurance a. GI system that nothing will go wrong b. Central nervous system c. Discuss alternate methods to promote c. Renal system uterine readiness and contractions d. Cardiovascular system d. Say it is the best way to get through labor and not a problem 81. When speaking with a primigravida about the way a baby develops, you would describe the 75. L. M. is a G2 P1001 whose initial visit reveals a embryonic stage as the: healthy pregnant woman. Her urinalysis and culture and sensitivity (C&S) report indicates a a. Period between the second and eighth colony count of greater than 100,000 organisms/ weeks mL. You would: b. Time from implantation to 12 weeks into pregnancy a. Refer her to a urologist to evaluate for c. Period when drugs are least likely to affect underlying renal disease development b. Encourage fluids and repeat C&S in 2 weeks d. Period from fertilization to 4 weeks c. Initiate treatment with antibiotics d. Advise her to contact you if she has any UTI 82. During the embryonic stage all major organ symptoms systems are formed except: 76. Antepartal care for the woman who is HIV posi- a. Heart tive should focus mainly on: b. Reproductive organs c. Liver a. Assuring fetal well-being at all cost d. Lungs b. Frequent drug testing to assure she is not using IV street drugs 83. Determining an accurate estimated date of c. Getting her partner tested and treated if birth (EDB) is critical because: necessary a. It is the basis for making decisions toward d. Maintaining her health and preventing the end of the pregnancy. neonatal transmission b. Mothers want to know the exact date the 77. On reviewing the record of a currently preg- baby will be born. nant woman, you see that she is P1112. What c. It is all that is needed to plan a 37-week obstetrical history can you derive from this elective C-section. information ? d. Families want to make plans around the baby’s birth. a. Two previous pregnancies of which one infant was term and one was a premature 84. Which of the following would not be a stillbirth normal physical examination finding during b. You are unable to determine an obstetric pregnancy? history from this information a. Blue color of vaginal mucosa and cervix c. Three pregnancies with one term birth and b. Hypertrophy of nasal mucosa and gums premature twins c. Mildly enlarged, nodular thyroid d. Three pregnancies of which one was term, d. Increased redness on palms of hands one premature and one abortion 85. During the last 8 weeks of pregnancy, the fetus: 78. Polyhydramnios is defined as: a. Finishes the final formation of the renal a. AFI greater than 10 cm system b. Single pocket greater than 5 cm b. Completes the development of reproduc- c. AFI greater than 15 cm tive organs d. Single pocket greater than 8 cm c. Experiences the closure of the foramen 79. Etiology of polyhydramnios is associated with: ovale d. Increases weight through fat accumulation a. Maternal over-hydration b. Fetal anomalies of GI tract 86. The determination of an accurate EDB is best c. Fetal anomalies of cardiovascular system accomplished by using: d. Maternal preeclampsia with edema Questions 127

a. The first day of the last menstrual period a. Lower diastolic blood pressure in third b. A complete menstrual history trimester c. The use of Naegele’s rule b. 10% cardiac volume increase that peaks in d. Date when symptoms of pregnancy began midpregnancy c. Resting pulse increase of 10–15 beats in 87. Dating of pregnancy by USG is most accurate in first trimester the first trimester using: d. Slight decrease in cardiac output in second a. Crown rump length (CRL) trimester b. Head circumference 94. The usual 1 g drop in hemoglobin during preg- c. Abdominal circumference nancy is due to: d. Femur length a. Blood volume increase of 30–50% 88. Which of the following statements most accu- b. Decrease in iron absorption rately reflects the growth of the pregnant c. Decrease in production of RBC uterus? d. Increasing iron needs of the fetus a. At 14 weeks it begins to rise out of the 95. Which of the following is considered a pelvis, and at 24 weeks is at the umbilicus. risk factor for psychological well-being in b. At 14 weeks it is halfway to the umbilicus, pregnancy? and at 20 weeks is at the umbilicus. c. At 12 weeks it begins to rise out of pelvis, a. Limited support network and at 20 weeks is at the umbilicus. b. Introversion at any point d. At 10 weeks it begins to rise out of the c. Ambivalence anytime pelvis, and at 16 weeks is at the umbilicus. d. Concern about the danger signs 89. Which of the following is a presumptive sign of 96. The maternal mortality ratio is defined as the pregnancy seen in the vagina? number of maternal deaths that result from the reproductive process per: a. Hegar’s b. Piskacek’s a. 1000 live births c. Goodell’s b. 100,000 live births d. Chadwick’s c. 100,000 pregnant women d. 100,000 reproductive age women 90. The pregnancy is maintained through hormones produced by: 97. G. R. comes for her first pregnancy visit. Her obstetrical history includes one spontaneous a. Egg sac and placenta abortion, one termination of pregnancy, one b. Corpus luteum and chorion infant born at 36 weeks and one born at 41 c. Corpus luteum and placenta weeks. Both infants are living. Her parity is: d. Ovary and placenta a. 2022 91. Of the four pelvic types, which is more likely to b. 2122 lead to a posterior position with higher possi- c. 1212 bility of dystocia? d. 1122 a. Android 98. The pelvic planes of obstetrical significance are b. Platypelloid the: c. Anthropoid d. Gynecoid a. Inlet, midplane, and outlet b. Inlet, posterior outlet, and anterior outlet 92. The characteristic gait of pregnancy results c. Inlet, posterior midplane, and anterior from: midplane a. Shift in the center of gravity as uterus d. Linea terminalis, posterior outlet, and ante- enlarges rior outlet b. Effects of relaxin and estrogen 99. Which of the elements of clinical pelvimetery c. Effects of relaxin and progesterone defines the midplane? d. Effects of increasing amounts of estrogen and progesterone a. Diagonal conjugate b. Intertuberous diameter 93. The effect of pregnancy on the cardiovascular c. Ischial spines distance and sacrum system is most clearly seen in: d. Pubic arch 128 Chapter 4 Pregnancy

100. Amniocentesis is used in early pregnancy to: 107. Which of the following is most common during pregnancy? a. Screen for fetal anomalies b. Diagnose fetal genetic well-being a. Binge drinking c. Evaluate maternal genetic problems b. Cigarette smoking d. Determine AFI and muscle tone c. Marijuana smoking d. Occasional alcohol use 101. Chorionic villous sampling (CVS) has an advantage over amniocentesis because it: 108. When faced with a woman who manifests clear evidence of being a victim of violence, your first a. Can be done 3–4 weeks earlier goal is: b. There is less risk for infection c. There is less risk for limb deformities a. Evaluate her safety d. There is greater specificity in test results b. Get her to a shelter c. Tell her to press charges 102. When considering the use of fetal movement d. Get photos of all injuries counting for a particular woman, it is important to know that: 109. Correct information concerning pregnancies with first trimester bleeding includes: a. Fetuses move constantly so it can be done at any time. a. Approximately 10% of women have some b. Fetal movement is strongest at 29–38 bleeding in the first trimester. weeks. b. Bleeding that occurs between 10 and 12 c. Most women don’t feel the fetus move weeks is often caused by implantation. before 24 weeks. c. Cervical incompetence is a common cause d. There is only one way to perform fetal of first trimester bleeding. movement counts. d. 90% of pregnancies in which FHT are heard will continue to term after early bleeding. 103. The basis for the nonstress test (NST) to assess fetal well-being is that: 110. A patient presents with an LMP of 8 weeks ago and a positive urine pregnancy test. She a. Fetal movement will increase the mother’s is having a small amount of bleeding for the heart rate. past 12 hours, along with some mild abdominal b. The fetus responds to an increase in heart cramping. A pelvic exam reveals a closed cervix rate by accelerating movement. and a slightly enlarged uterus. Differential c. Fetal movement should cause no significant diagnosis for this woman includes: change in FHR. d. Fetal heart rate accelerates in association a. Complete abortion and threatened with fetal movement. abortion b. Ectopic pregnancy and inevitable abortion 104. Contraindications to contraction stress testing c. Ectopic pregnancy and threatened abortion (CST) include: d. Incomplete abortion and inevitable a. Gestational age greater than 37 weeks abortion b. History of ectopic pregnancy 111. An example of an autosomal recessive disease c. Nonreactive nonstress test (NST) is: d. Placenta previa a. BRCA 2 breast cancer 105. Cordocentesis may be used: b. Cystic fibrosis a. As an adjunct to chorionic villi sampling c. Hemophilia (CVS) d. Trisomy 21 b. To obtain blood samples for fetal 112. A 34-week pregnant woman presents stating fibronectin test she noticed a small amount of blood on her c. To provide fetal blood transfusion underwear this morning about an hour after d. To relieve pressure on a prolapsed cord having sexual intercourse. She is not having any 106. Substances classified as addictive: pain or contractions. Your initial differential diagnosis for this woman would include: a. Are only illegal drugs b. Include only those inhaled or injected a. Cervicitis c. Include both legal and illegal drugs b. Incompetent cervix d. Do not include alcohol Questions 129

c. Placental abruption 119. An elevated maternal AFP result is associated d. Premature rupture of membranes with which of the following? 113. Risks to the fetus in a postterm pregnancy are a. Down syndrome related to all of the following except: b. Neural tube defect c. Autosomal recessive gene a. Fetal macrosomia d. X-linked recessive inheritance b. Meconium aspiration c. Polyhydramnios 120. Which of the following factors would predis- d. Uteroplacental insufficiency pose a pregnant woman to having a baby with GBS disease? 114. Symmetric growth restriction is more likely than asymmetric growth restriction to: a. History of previous GBS-positive infant b. Bacterial vaginosis in current pregnancy a. Be related to multiple gestation c. Frequent urinary tract infections prior to b. First become apparent in late pregnancy pregnancy c. Occur as a result of maternal medical illness d. Streptococcal pharyngitis in the third d. Result from maternal cigarette smoking trimester 115. Loss of a fetus in the second trimester is most 121. V. R. comes for her 38-week visit, during which frequently related to: she reports that her friend gave birth last week a. Hydatidiform mole and had a placental abruption. She is now con- b. Inevitable abortion cerned that she might have the same. What c. Ectopic pregnancy information would you share with her about d. Incompetent cervix this? 116. As a result of an early USG, a low-lying pla- a. In the event of bleeding near term, 50% centa is verified for B. T. What do you tell her are related to placental abruption. regarding this? b. In the third trimester, she has a 30% chance of having a placental abruption. a. Approximately 30% of women with low- c. The likelihood of her having this occur is lying placenta in early pregnancy will have basically zero at this time. placenta previa in the third trimester. d. It is associated with risk factors such as b. Approximately 30% of women have a low- hypertension, smoking, and trauma. lying placenta in the first trimester. c. Regular vaginal examinations will be 122. Genotype refers to: done in the third trimester to monitor any a. The expression of genes present in an obstruction of the cervix. individual d. Vaginal delivery is contraindicated if there b. The dominant genes that will be inherited is a marginal placenta previa. by a fetus 117. A pregnant woman has the following history: c. The pair of genes for each characteristic vaginal delivery at 38 wks; spontaneous abor- inherent in an individual tion at 8 wks; elective abortion at 13 wks; d. The recessive genes that will be passed on vaginal delivery at 34 wks; 2 living children; is to a fetus now 28 wks pregnant. Her gravity and parity 123. Which of the following women should receive are: RhoGAM postpartum? a. G5 P1122 a. Nonsensitized Rh negative mother with an b. G5 P0222 Rh negative baby c. G3 P2002 b. Nonsensitized Rh negative mother with an d. G3 P2112 Rh positive baby 118. Which of the following tests is diagnostic rather c. Sensitized Rh negative mother with an Rh than screening? negative baby d. Sensitized Rh negative mother with an RH a. MSAFP positive baby b. Nuchal translucency US c. Amniocentesis 124. Aneuploidy describes which of the following d. USG at 10 weeks situations? 130 Chapter 4 Pregnancy

a. Down syndrome 129. Symmetric intrauterine growth restriction: b. BRCA 1 and 2 inheritance a. Generally becomes evident in c. Cystic fibrosis genes midpregnancy d. Sickle cell anemia b. Is usually associated with placental 125. B. T., G2 P0010, comes for her first antepartal abnormalities visit. Her history indicates she had a pregnancy c. Is caused by conditions that result in a loss at 18 weeks. She is gravely concerned that reduction in cell size it will happen again in this pregnancy. You d. Is a neonatal diagnosis made when the discuss cervical cerclage, mentioning the fol- infant falls below the 10th percentile lowing facts: 130. M. K. is a 34-year-old G5 P4004. Her 1-hour a. Will be done after 12–14 weeks and is 50 g glucose challenge test at 28 weeks was 154 80–90% successful mg/dL. Follow-up 100 g glucose tolerance test b. Will be done after 16–20 weeks and is produced the following results: 100, 192, 185, 80–90% successful and 160 mg/dL. Your plan for M. K. includes: c. Will be done after 16–20 weeks and is a. Obtaining fasting glucose tests at 32 and 36 50–60% successful weeks to assure that levels stay at or below d. Will be done after 12–14 weeks and is 100 mg/dL 50–60% successful b. Referring her to a nutritionist to help her 126. The CDC’s recommended treatment for primary limit further weight gain to no more than syphilis in a 10-week pregnant woman is: 10 lb. c. Referring her to a perinatologist for peri- a. Benzathine penicillin G 2.4 units IM x 1 umbilical blood sampling to determine dose after the first trimester fetal blood glucose levels b. Benzathine penicillin G 2.4 units IM x 1 d. Screening for diabetes at 6–12 weeks dose at the time of diagnosis postpartum c. Benzathine penicillin G 2.4 units IM weekly x 3 doses 131. At 20 weeks’ gestation a pregnant woman d. Benzathine penicillin G 2.4 units IM at the was seen and fundal height was 1 cm below time of diagnosis and repeat in 4 weeks if the umbilicus. At today’s 24-week visit, fundal no decline in RPR titer height is at the umbilicus. She is feeling regular fetal movement and fetal heart rate is 140 127. At an initial prenatal visit, a woman is diag- bpm. The most appropriate management for nosed with bacterial vaginosis. She is not this patient is: having any symptoms of vaginal infection. You will advise her that: a. Ordering a biophysical profile b. Ordering an ultrasound a. All pregnant women should be treated if c. Performing a nonstress test at this visit they have asymptomatic bacterial vaginosis. d. Scheduling her next visit for 4 weeks from b. Pregnant women who are at risk for today preterm delivery should be treated if they have asymptomatic bacterial vaginosis. 132. Ectopic pregnancy is consistent with no intra- c. Only pregnant women at risk for preterm uterine sac on transvaginal ultrasound and an delivery should be treated for symptomatic hCG titer of less than: bacterial vaginosis. a. 100 IU/L d. Pregnant women who are at risk for b. 1500 IU/L preterm delivery should be tested for c. 6500 IU/L asymptomatic bacterial vaginosis in early d. 10,000 IU/L third trimester. 133. L. H. is an 18-year-old female who is 16 weeks 128. CDC’s recommended treatment for trichomo- pregnant. She has a positive chlamydia test. niasis during pregnancy is: Appropriate management includes: a. Metronidazole 2 g orally a. Erythromycin base 500 mg orally qid for 7 b. Clindamycin 300 mg orally bid x 7 days days and ceftrixone 125 mg IM c. Azithromycin 1 g orally b. Azithromycin 1 g orally in a single dose and d. Ceftriaxone 125 mg IM perform test of cure in 3–4 weeks Questions 131

c. Ofloxacin 300 mg orally bid for 7 days and a. Obtaining a CBC and ferritin level rescreen in the third trimester b. Asking if she is having difficulty tolerating d. Spectinomycin 2 g IM now and repeat in 1 her iron supplement and change to a dif- week ferent type if needed c. Rechecking her history to see if she may be 134. M. I. is a 29-year-old G4 P2012 at 41 weeks at risk for an inherited anemia today. She complains of occasional cramping, d. Encouraging her to continue getting denies leaking/bleeding, but states she passed dietary iron and taking her iron supplement her “mucus plug” yesterday. She asks how she’ll know if she’s in labor since both her previous 139. Folic acid deficiency anemia is characterized by: births were induced. You respond that: a. Hemoglobin at 9 g/dL or less a. True labor occurs when contractions are 7–8 b. Low ferritin levels minutes apart and last for 45 seconds. c. Elevated serum iron binding capacity b. Real labor is when contractions are 2–3 d. Macrocytic erythrocytes minutes apart and are very painful. 140. Which of the following statements is true con- c. Labor contractions usually become more cerning sickle cell hemoglobinopathies: regular and more intense over time. d. Contractions begin slowly; once they are a. Trait indicates that one parent has sickle 4–5 minutes apart, it is real labor. cell disease. b. Disease is present when the person inherits 135. Hyperthyroidism in pregnancy is diagnosed by: a sickle cell gene from each parent.

a. Elevated free thyroxine (T4) levels c. G-6-PD deficiency is a potential complica-

b. Low free T3 levels tion of sickle cell disease. c. Elevated TSH d. 1 in 100 African Americans has sickle cell

d. Elevated total thyroxine (TT4) levels trait. 136. ABO incompatibility occurs in what percentage 141. Normal changes of pregnancy may confound of pregnancies? a diagnosis of appendicitis. With this in mind, you should note the following as a critical sign a. 15% or symptom pointing to possible appendicitis in b. 20–25% pregnancy: c. 25–40% d. 5–8% a. Persistent abdominal pain and tenderness b. Intermittent lower abdominal cramping 137. T. W., a 32-year-old G2 P1001, is Rh negative. c. Elevated WBC level Her first pregnancy was uneventful, and she d. Nausea and vomiting received RhoGAM after the birth. She read on the Internet that problems were much more 142. M. D., a 32-year-old P1, during a discussion of likely with the second pregnancy. You respond infant care and breastfeeding, says, “My first that: baby didn’t like the breast, then I didn’t have enough milk, so I stopped breastfeeding after a. Since she reports she has had no transfu- two weeks.” What is your response to her sions since the previous birth, there is no statement? problem. b. The RhoGAM she received in the last preg- a. Tell her she probably misinterpreted what nancy will prevent any problems in this was going on and shouldn’t have stopped pregnancy. nursing. c. She was not sensitized in the first preg- b. Delve further into what occurred and how nancy, and you will provide monitoring and she came to the conclusions that led her to treatment to prevent it in this pregnancy. stop breastfeeding. d. It is likely that her fetus is Rh– so there is no c. Let her know she probably wasn’t drinking real concern that she will have any prob- enough fluids so didn’t have enough milk lems related to this. to feed the baby. d. Reassure her that she was listening to her 138. At 28 weeks’ gestation, a patient’s Hgb is 11.2 body and had done the right thing for g/dL. At her initial first trimester visit, her Hgb herself and her infant. was 12.8 g/dL. Management will include: 132 Chapter 4 Pregnancy

143. M. B., G1 P0, comes for her 36-week visit with a 147. Which of the following statements concerning piece of paper in her hand. “I’m really confused HIV in women is correct? about this birth plan business. What am I sup- a. The main route of acquiring the infection posed to do about my birth? Don’t I just show in women is IV drug use. up when I’m in labor?” How will you counsel b. Viral load is the strongest predictor for her today? transmission of infection to infant during a. “It really doesn’t matter what you write birth process. because the hospital has its own plan.” c. C-section is the recommended route of b. “You will need to be very detailed about delivery for all HIV-infected women to each element of the birth experience so reduce the risk of transmission of infection you get what you want.” to infant. c. “The plan provides the opportunity for you d. Breastfeeding should only be recom- to make choices about events associated mended if the mother’s viral load is less with the birth.” than 200 copies/ml. d. “The healthcare provider who is there 148. S. R. has reached her 39th week of pregnancy. when you are in labor will tell you what is On abdominal exam you measure a fundal best for you and how to do it.” height of 42 cm. Leopold’s maneuvers provides 144. Y. L., G2 P1001, comes for her first visit. She is you with an EFW of 4200 g. What factors would concerned about the possibility of a UTI since help to ease your mind about the fetal size? her sister was recently hospitalized for pyelo- a. She has wide hips and will have no problem nephritis. What facts would you give her to with a big baby. enhance her understanding? b. She is 5 ft 10 in with an anthropoid pelvis a. UTIs do occur in about 10% of pregnancies. and her husband is 6 ft 4 in. b. 25% of women with UTI in pregnancy will c. She is totally unconcerned and knows this develop pyelonephritis. baby will fit. c. If she has a history of UTIs before preg- d. The fetus is not yet engaged so the height nancy, she will be screened with a urine is greater than expected. culture each trimester. 149. Many conditions are associated with preterm d. Pregnant women are typically screened birth. Of the 28% of births that occur preterm, for asymptomatic bacteruria in early what is the condition that contributes most to pregnancy. these births? 145. Who is at greatest risk for developing a UTI in a. IUGR pregnancy? b. Preeclampsia a. Adolescents c. Fetal demise b. Woman pregnant with twins d. Abruptio placenta c. Women older than 35 years 150. A patient who is 32 weeks pregnant has had d. Woman with diabetes symptoms of preterm labor and has a history 146. L. T. returns for the reading of the PPD that was of preterm delivery at 34 weeks. A fetal placed during her first prenatal visit. You read fibronectin test is negative. You advise her that: the result as 10 mm of induration. L. T. is a. She has a 60% chance of going into labor American-born, healthy, and has no known within the next week. history of contact with the disease. How do b. It is really too early in her pregnancy for you interpret this result to her? this test to be of much value. a. It is positive and she needs referral to an c. The result offers some reassurance that she infectious disease specialist. will not go into labor in the next 2 weeks. b. It is unclear and she should have a chest d. It is really too late in her pregnancy for this radiograph to be certain. test to be of much value. c. It is positive and you should give her a pre- 151. A decision is made to start tocolytic therapy for scription for INH. a 30-week gestation woman in preterm labor. d. It is negative since she has no high-risk Betamethasone IM has also been ordered. characteristics for the disease. This is done because the administration of corticosteroids: Answers 133

a. Decreases the respiratory side-effects of 49. c 102. b tocolytic drugs 50. a 103. d b. Decreases the incidence of premature 51. c 104. d rupture of membranes 52. a 105. c c. Enhances the effects of tocolytic drugs 53. c 106. c d. Reduces the incidence of newborn respiratory distress syndrome 54. c 107. b 55. a 108. a 152. G. F. comes for her 32-week visit, and you deter- 56. d 109. d mine she has a breech presentation. Your plan 57. d 110. c for her is to: 58. b 111. b a. Send her to Maternal Fetal Medicine for 59. b 112. a external cephalic version 60. a 113. c b. Refer her to perinatologist for care decision 61. d 114. d and treatment 62. c 115. d c. Send her for ultrasound to confirm breech 63. b 116. b presentation 64. a 117. a d. Wait until 36 weeks to see if spontaneous 65. c 118. c version has occurred 66. a 119. b 153. A pregnant woman presents for her 32-week 67. b 120. a visit with no complaints. All findings from pre- 68. d 121. d vious visits have been normal. Today she has 69. c 122. c blood pressure of 145/95. Expected additional 70. b 123. b findings if she has mild preeclampsia include: 71. b 124. a a. Lower extremity edema 72. a 125. a b. 1 to 2+ proteinuria on dipstick urine 73. b 126. b c. Right upper epigastric pain 74. c 127. b d. Elevated liver function tests 75. c 128. a 76. d 129. a Â Answers 77. d 130. d 78. d 131. b â 1. b â 25. d 79. b 132. c â 2. c â 26. b 80. c 133. b â 3. b â 27. a 81. a 134. c â 4. b â 28. c 82. d 135. a â 5. d â 29. b 83. a 136. b â 6. a â 30. a 84. c 137. c â 7. c â 31. c 85. d 138. d â 8. c â 32. d 86. b 139. d â 9. b â 33. b 87. a 140. b 10. d â 34. d 88. c 141. a 11. a â 35. a 89. d 142. b 12. c â 36. b 90. c 143. c 13. d â 37. c 91. a 144. d 14. b â 38. c 92. c 145. d 15. c â 39. b 93. b 146. d 16. c â 40. c 94. a 147. b 17. a â 41. d 95. a 148. b 18. b â 42. c 96. b 149. b 19. d â 43. b 97. d 150. c 20. b â 44. a 98. a 151. d 21. a â 45. c 99. c 152. d 22. b â 46. d 100. b 153. b 23. c â 47. b 101. a 24. a â 48. b 134 Chapter 4 Pregnancy

Â Bibliography Centers for Disease Control and Prevention (CDC). (2008). TB elimination: Tuberculosis and pregnancy. Advisory Committee on Immunization Practices (ACIP). Atlanta, GA: Author. Retrieved on May 2, 2010 (2009). Recommended adult immunization schedule from http://www.cdc.gov/tb/publications/factsheets/ United States. Atlanta, GA: Department of Health and specpop/pregnancy.htm. Human Services—Centers for Disease Control and Chernecky, C., & Berger, B. (2008). Laboratory tests and Prevention. diagnostic procedures (5th ed.). St. Louis: Saunders American College of Obstetricians and Gynecologists Elsevier. (ACOG). (2008). Anemia in pregnancy. Practice Bul- Coad, J., & Dunstall, M. (2005). Anatomy and physiology letin No. 95. Washington, DC: Author. for midwives (2nd ed.). St. Louis: Mosby, Inc. American College of Obstetricians and Gynecologists Coustan, D. (2007). Pharmacologic management of (ACOG). (2007). Management of herpes in pregnancy. gestational diabetes. Diabetes Care, 30 (Suppl 2), Practice Bulletin No. 82. Washington, DC: Author. 206–208. American College of Obstetricians and Gynecologists Cunningham, F., Leveno, K., Bloom, S., Hauth, I., Rouse, (ACOG). (2004). Management of postterm pregnancy. D., & Spong, C. (2009). Williams obstetrics (23rd ed.). Practice Bulletin No. 55. Washington, DC: Author. New York: McGraw-Hill. American College of Obstetricians and Gynecologists Enkin, M., Kreiree, M., Nelison, J., & Crowther, C. (2000). (ACOG). (2000). Intrauterine growth restriction. Prac- A guide to effective care in pregnancy and childbirth tice Bulletin No. 10. Washington, DC: Author. (3rd ed.). Oxford, UK: Oxford University Press. American College of Obstetricians and Gynecologists Gibbs, R., Karlan, B., Haney, A., & Nygaard, I. (2008). (ACOG). (2001). Management of recurrent early preg- Danforth’s obstetrics and gynecology (10th ed.). Phila- nancy loss. Practice Bulletin No. 24. Washington, DC: delphia, PA: Lippincott, Williams, and Wilkins. Author. HIV/AIDS Bureau. (2005). A guide to the clinical care American College of Obstetricians and Gynecologists of women with HIV/AIDS, 2005 edition. Washington, (ACOG). (2001). Chronic hypertension in pregnancy. DC: US Department of Health and Human Services. Practice Bulletin No. 29. Washington, DC: Author. Hunter, L., Sullivan, C., Young, R., & Weber, C. (2007). American College of Obstetricians and Gynecologists Nausea and vomiting of pregnancy: Clinical manage- (ACOG). (2001). Gestational diabetes. Practice Bulle- ment. The American Journal of Nurse Practitioners, tin No. 30. Washington, DC: Author. 11(8), 57–67. American College of Obstetricians and Gynecolo- Institute of Medicine. (2009). Weight gain during preg- gists (ACOG). (2002). Diagnosis and management nancy: Reexamining the guidelines. Washington, DC: of preeclampsia/eclampsia. Practice Bulletin No. 33. Institute of Medicine. Washington, DC: Author. King, T., & Murphy, P. (2009). Evidence-based ap- American College of Obstetricians and Gynecologists proaches to managing nausea and vomiting in early (ACOG). (2004). Nausea and vomiting of pregnancy. pregnancy. Journal of Midwifery and Women’s Health, Practice Bulletin No. 52. Washington, DC: Author. 54(6), 430–444. American College of Obstetricians and Gynecologists Naegele, M. A., & D’Avanza, C. E. (2001). Addictions and (ACOG). (2001). Assessment of risk factors for pre- substance abuse. Upper Saddle River, NJ: Prentice term birth. Practice Bulletin No. 31. Washington, DC: Hall. Author. Sibai, B. (2005). Preeclampsia. Lancet, 365(9461), American Diabetes Association. (2009). Standards of 785–799. medical care in diabetes—2009. Diabetes Care, 32 Substance Abuse and Mental Health Services Admin- (Suppl 1), S13–S61. istration (SAMHSA) (2009). Results from the 2008 Branson, B., Handsfield, H., Lampe, M. et al. (2006). national survey on drug use and health: National Revised recommendations for HIV testing of adults, findings. NSDUH Series H-36, HHS Publication No. adolescents, and pregnant women in healthcare set- SMA 09-4434. tings. MMWR, 55(RR14), 1–17. Tharpe, N., & Farley, C. (2009). Clinical practice guide- Centers for Disease Control and Prevention (CDC). lines for midwifery and women’s health (3rd ed.). Sud- (2005). Achievements in public health: Elimination bury, MA: Jones and Bartlett. of rubella and congenital rubella syndrome—United Varney, H., Kriebs, J., & Gegor, C. (2004). Varney’s mid- States, 1969–2004. MMWR, 54(RR11), 279–282. wifery (4th ed.). Sudbury, MA: Jones and Bartlett. Centers for Disease Control and Prevention (CDC). Wynne, A., Woo, T., & Olyaei, A. (2007). Pharmacothera- (2008). STD surveillance 2007. Atlanta, GA: Author. peutics for nurse practitioner prescribers (2nd ed.). Retrieved on May 2, 2010 from http://www.cdc.gov/ Philadelphia, PA: F. A. Davis. std/stats07/main.htm. Centers for Disease Control and Prevention (CDC). (2008). Reported tuberculosis in the United States, 2007. Atlanta, GA: Author. 5 Midwifery Care of the Newborn

Anthony A. Lathrop

¶ PHYSIOLOGIC TRANSITION TO b. Irregular/fluctuating pattern EXTRAUTERINELIFE c. Diaphragmatic and abdominal breathing d. Obligate nose breathing UÊ i`>ÌiÊiÝÌÀ>ÕÌiÀiÊÌÀ>ÃÌpi`>ÌiÊ e. Absence of nasal flaring, grunting, and transition from intrauterine to extrauterine life retractions depends on changes in four major areas: respiration, circulation, thermoregulation, and glucose UÊ ÀVÕ>ÌÀÞÊV >}iÃ regulation 1. Transition from fetal to adult circulation begins with clamping of the umbilical cord and UÊ ,iÃ«À>ÌÀÞÊV >}iÃ continues throughout the first weeks of life £°Ê ÕÃÌÊi`>ÌiÞÊLi}ÊÀiÃ«À>ÌÊÕ«Ê Ó°Ê >À>VÌiÀÃÌVÃÊvÊviÌ>ÊVÀVÕ>Ì `iÛiÀÞ >°Ê Ü«ÀiÃÃÕÀiÊÃÞÃÌi]ÊVÕ`}Ê«>ViÌ>Ê 2. Factors in initiation of respiration (low-resistance circuit) >°Ê V iV>pÀi>ÌÛiÊ Þ«Ý>Ê>ÌÊÌ iÊi`Ê L°Ê >ÊVÀVÕ>ÌÊÌÊÕ}ÃÆÊLÞ«>ÃÃi`ÊÛ>Ê of labor vÀ>iÊÛ>i L°Ê * ÞÃV>ÊÃÌÕpV`]Ê}À>ÛÌÞ]Ê«>]Ê} Ì]Ê V°Ê ÕVÌÕÃÊ>ÀÌiÀÃÕÃÊv>ÛÀÃÊVÀVÕ>ÌÊÌÊÌ iÊ noise brain V°Ê ,iVÊvÀÊ«ÀiÃÃÕÀiÊÊÌ À>ÝÊÜ iÊ«>ÃÃ- 3. Transition from fetal to neonatal circulation }ÊÌ ÀÕ} ÊÛ>}> >°Ê VÀi>Ãi`ÊÃÞÃÌiVÊÀiÃÃÌ>ViÊ`ÕiÊÌÊÃÃÊ 3. Sustained respiration depends on coordinated of placental circuit response of the following: b. Increased pressure in left atrium causes >°Ê iÌÀ>ÊiÀÛÕÃÊÃÞÃÌiÊ -®ÊÀiÃ«À>ÌÀÞÊ vÕVÌ>ÊVÃÕÀiÊvÊvÀ>iÊÛ>i center V°Ê Ì>ÊÀiÃ«À>ÌÊ«iÃÊ«Õ>ÀÞÊÛ>Ã- b. Aortic and carotid chemoreceptors VÕ>ÌÕÀi]Êv>ÛÀ}ÊVÀVÕ>ÌÊÌÊÕ}Ã c. Thoracic mechanoreceptors `°Ê VÀi>Ãi`ÊÝÞ}i>ÌÊvÊVÀVÕ>Ì}ÊL`Ê `°Ê >« À>}Ê>`ÊÀiÃ«À>ÌÀÞÊÕÃViÃ causes constriction and functional closure {°Ê Ì>ÊLÀi>Ì }ÊÃiÀÛiÃÊÌ iÊvÜ}Ê«ÕÀ«ÃiÃ\ of ductus arteriosus >°Ê ÃÃÃÌÊÊVÛiÀÃÊvÀÊviÌ>ÊÌÊiÝÌÀ>- e. Absence of placental circulation closes uterine circulation `ÕVÌÕÃÊÛiÃÕÃ L°Ê i>ÀÊÕ}ÃÊvÊvÕ` V°Ê ÃÌ>LÃ ÊÕ}ÊÛÕiÊ>`ÊiÝ«>`Ê>Ûi UÊ / iÀÀi}Õ>Ì x°Ê >À>VÌiÀÃÌVÃÊvÊÀ>ÊiÜLÀÊÀiÃ«À>Ì 1. Mechanisms of neonatal heat loss >°Ê ,iÃ«À>ÌÀÞÊÀ>ÌiÊÎäÊÌÊÈäÊLÀi>Ì ÃÊ«iÀÊ >°Ê ÛiVÌ minute L°Ê `ÕVÌ

135 136 Chapter 5 Midwifery Care of the Newborn

c. Radiation 4. Signs and symptoms of hypoglycemia d. Evaporation a. Weak cry 2. Neonate creates heat in three ways: b. Jitteriness a. Shivering (inefficient) c. Cyanosis b. Muscle activity (limited benefit) d. Apnea c. Thermogenesis by metabolism of brown e. Lethargy adipose tissue (BAT) f. Poor feeding (1) BAT stores are decreased in preterm 5. Management and growth-restricted fetuses a. Encourage feeding as soon as possible (2) BAT stores are nonrenewable b. Observe for signs/symptoms of (3) Hypoglycemia decreases efficiency of hypoglycemia BAT metabolism c. Assess glucose levels if signs/symptoms or 3. Consequences of cold stress risk factors are present a. Increased oxygen consumption, leading to (1) Profound severity at less than 20–25 relative hypoxia and acidosis mg/dL b. Metabolism of BAT and release of fatty ac- (2) Moderate severity at 25–34 mg/dL ids decreases pH (3) Minimal severity at 35–45 mg/dL c. Increased use of glucose, depletion of gly- d. Indications for treatment with intravenous cogen stores, and hypoglycemia dextrose d. Worsening hypoglycemia and acidosis (1) Symptomatic infants, or those with may result in respiratory distress initial serum glucose less than 25 4. Management mg/dL a. Skin-to-skin on mother’s chest or abdo- (2) Asymptomatic infants with persistent men with blanket over both serum glucose less than 40 mg/dL b. Pre-warm blankets and resuscitation area c. Dry the newborn immediately and replace Â Ongoing Extrauterine wet blankets Transition d. Regulate room temperature and minimize exposure to air convection • Changes in the blood e. Postpone newborn bath at least 2 hours 1. Red blood cells (RBC) f. Keep newborn warm and wrapped a. Hemoglobin F (1) Predominates in fetal circulation • Glucose regulation (2) High affinity for oxygen 1. Glycogen stores (3) Gradually eliminated in first month of a. Predominantly in liver life b. Accumulated in third trimester b. Short RBC life span leads to increased bili- 2. Risk factors for neonatal hypoglycemia rubin and physiologic jaundice a. Infants of diabetic mothers c. Infant position at cord clamping b. Intrauterine growth restriction (1) Below introitus—may cause placental c. Preterm or postterm transfusion and polycythemia d. Intrapartum—fetal distress, beta-agonist (2) Neutral position on maternal abdo- tocolysis, IV glucose administration men is preferable e. Maternal substance abuse d. Normal values 3. Glucose regulation in the healthy neonate (1) Hemoglobin a. Normal physiologic decrease in blood (a) Newborn 13.7–20.0 g/dL glucose (b) Slight rise in first few days of life (1) Lowest at 1 to 1.5 to 5 hours after birth due to decreased plasma volume (2) Stabilizes at 3 to 4 hours after birth (c) Mean value at 2 months of age (3) Should not drop below 40 mg/dL 12.0 g/dL (some place cutoff at 60 mg/dL) (2) Hematocrit 43–63% b. Mean glucose levels from 4 to 72 hours are (3) RBC count 4.2–5.8 million/mm3 60 to 70 mg/dL (4) Reticulocytes 3–7% c. Sources and mechanisms of glucose 2. White blood cells (WBC) normal maintenance value—10–30,000/mm3 (1) Intake of human milk or formula 3. Platelets (2) Glycogenolysis (use of glycogen a. Normal value—150–350,000/mm3 stores) b. Relatively low levels of vitamin-K– (3) Gluconeogenesis (use of lipid stores) dependent clotting factors Immediate Care and Assessment of the Healthy Newborn 137

4. Obtaining blood samples 3. Immature tubular function a. Venous stasis in extremities may lead to a. Relative inability to concentrate urine false values from heel-stick samples b. Predisposition to fluid and electrolyte b. Maximize blood flow by using heel imbalances warmer before obtaining sample c. Confirm abnormal results with venipunc- Â Immediate Care and ture sample Assessment of the Healthy Newborn • Changes in the gastrointestinal (GI) system 1. Relatively mature aspects of the neonatal GI • Assessment prior to birth of pertinent maternal system history a. Suckling/swallowing 1. Genetic history b. Gag and cough reflexes a. Family history of structural or metabolic 2. Relatively immature aspects of the neonatal GI defects system b. History of genetic syndromes a. Limited ability to digest fats and proteins 2. Maternal elements b. Better absorption of monosaccharides a. Demographic factors than polysaccharides (1) Maternal age of younger than 16 or c. Frequent regurgitation due to older than 35 years (1) Incomplete development of cardiac (2) Overweight or underweight prior to sphincter pregnancy (2) Limited stomach capacity (less than (3) Maternal education less than 11 years 30 cc) (4) Family history of inherited disorders d. “Gut closure” b. Medical factors (1) Maturation process of intestinal lining (1) Cardiac disease and its enzymes and antibodies (2) Pulmonary disease (2) Vulnerability to bacteria, viruses, and (3) Renal disease allergens until process is complete (4) Gastrointestinal disease (3) Promoted by breastfeeding (5) Endocrine disorders, particularly dia- e. Large intestine betes or thyroid disease (1) Less efficient water conservation than (6) Chronic hypertension adult (7) Hemoglobinopathies (2) Predisposes infant to dehydration (8) Seizure or other neurologic disorders c. History of present pregnancy • Changes in the immune system (1) Late or no prenatal care 1. Natural immunity (2) Rh sensitization a. Physical and chemical barriers (skin, mu- (3) Fetus large or small for gestational age cosa, gastric acid) (4) Premature labor or delivery b. Phagocytes (neutrophils, monocytes, (5) Pregnancy-induced hypertension macrophages) (6) Multiple gestation (1) Immature phagocytic response (7) Polyhydramnios (2) Relative inability to localize infection (8) Premature or prolonged rupture of 2. Acquired immunity membranes a. Maternal IgG crosses placenta, conferring (9) Antepartum bleeding passive immunity to viruses the mother (10) Abnormal presentation has encountered (11) Postmaturity b. Breast milk provides maternal antibodies (12) Abnormal results in fetal testing c. Active production of IgG develops slowly (13) Anemia throughout childhood as passive immu- d. Psychosocial history nity diminishes (1) Inadequate financial, housing, or so- 3. Immaturity of natural and acquired immune cial resources systems predisposes the newborn to infection (2) Minority status and sepsis (3) Malnutrition (4) Parental occupation • Changes in the renal system (5) Significant relationships, marriage 1. Limited renal circulation status 2. Decreased glomerular filtration rate (6) Violence or abuse 138 Chapter 5 Midwifery Care of the Newborn

(7) Smoking during pregnancy (2) Suction mouth and nose, and trachea (8) Alcohol use during pregnancy as indicated (9) Drug use/abuse (3) Insert endotracheal (ET) tube to ensure open airway if necessary • Assessment at birth b. Initiate Breathing 1. During and immediately following birth (1) Use tactile stimulation to initiate a. Assess tone and skin color respirations b. Gross inspection of anatomy (2) Use positive pressure ventilation c. Place infant on maternal abdomen or ra- (PPV) with 100% oxygen when diant warmer necessary d. Palpate cord to assess heart rate c. Maintain Circulation—stimulate and 2. Apgar scoring maintain circulation with chest compres- a. Scale—0 to 10 sions and/or medications when necessary (1) Heart rate—0 = absent, 1 = <100, 5. Overview of resuscitation in the delivery room 2 = >100 a. Initial steps (2) Respiratory effort—0 = absent, (1) Place infant under radiant heater 1 = slow/irregular, 2 = strong cry (2) Suction trachea if meconium aspira- (3) Tone—0 = flaccid, 1 = flexion of ex- tion is suspected tremities, 2 = active motion (3) Dry infant; remove wet linen (4) Reflex irritability—0 = no response, (4) Suction mouth and nose 1 = grimace, 2 = strong cry (5) Provide tactile stimulation (5) Color—0 = general cyanosis, 1 = acro- b. Evaluate respirations, heart rate, and color cyanosis, 2 = completely pink (1) If no respirations, or heart rate less b. Assigned at 1 and 5 minutes; may be as- than 100 beats per minute (bpm), signed at additional 5-minute intervals provide positive-pressure ventilation when prolonged resuscitation efforts are (PPV) with oxygen required (a) If heart rate is below 60 bpm, c. Primary purpose of Apgar score—objec- continue PPV and initiate chest tive method of quantifying the newborn’s compressions condition and response to resuscitation (b) If heart rate is above 60 bpm, d. Poor predictor of long-term outcome continue PPV without chest e. Poor predictor of acidemia compressions f. Apgar score is not used to determine the c. Medications need for resuscitation, what resuscitation (1) Medications are initiated when the steps are necessary, or when to use them heart rate remains below 60 bpm after (Neonatal Resuscitation Steering Commit- 30 seconds of coordinated chest com- tee, 2000) pressions and PPV (2) Dosage based on infant weight • Review of neonatal resuscitation (American Acad- (3) Medications include emy of Pediatrics, 2006) (a) Epinephrine—increases strength 1. Midwives and nurse practitioners who care for and rate of cardiac contrac- women in the intrapartum setting should be tions and causes peripheral trained and certified in neonatal resuscitation; vasoconstriction the information presented here is a review, not (b) Volume expanders—recom- a substitute for training and certification mended solution is normal saline 2. Approximately 10% of newborns require some (c) Sodium bicarbonate—may be assistance to begin breathing at birth; about beneficial in correcting acidosis 1% require extensive resuscitation during prolonged resuscitation 3. Evaluation is based upon three signs (d) Naloxone—narcotic antagonist a. Respirations used when there is severe respira- b. Heart rate tory depression and a history of c. Color maternal narcotic administration 4. ABCs of resuscitation within the last 4 hours a. Establish an open Airway 6. Newborns with meconium-stained amniotic (1) Position the infant on back or side fluid with the neck slightly extended Care During the First Hours After Birth 139

a. Suction mouth, nose, and posterior phar- c. Slower, more regular respirations ynx after delivery of head but before deliv- d. Bowel sounds present but diminished ery of shoulders b. If the baby has a normal respiratory ef- • Second period of reactivity fort, normal tone, and heart rate greater 1. Lasts from 2 to 6 hours after birth than 100 bpm, use bulb syringe or suction 2. Assessment findings catheter to clear secretions and meconium a. Labile heart rate from mouth and nose—endotracheal suc- b. Rapid changes in color tioning is not indicated c. Respiration—rate less than 60/min with- c. If the baby has depressed respirations, out rales or rhonchi depressed tone, or heart rate less than 100 3. Early feeding bpm, endotracheal suctioning of meco- a. Infant may be interested in feeding during nium is indicated the second period of reactivity b. Prevention of hypoglycemia Â Care During the First Hours c. Stimulation of stool passage After Birth d. Prevention of jaundice

• Transitional period • Bonding and parent–newborn attachment 1. Time when the infant stabilizes and adjusts to 1. Definitions vary; generally referring to the pro- extrauterine life cess occurring in the time after birth whereby 2. Three stages the mother (and/or other family members) a. First period of reactivity form a unique, lasting relationship with the b. Period of unresponsive sleep newborn c. Second period of reactivity 2. Factors that may influence bonding 3. May be altered when the infant is significantly a. Parental background stressed in labor and delivery (1) Care that parents received from their 4. Preferred management for first hour of life; parents some say during hospital stay (2) Social/cultural factors a. Maintain contact with the mother (3) Couple and family relationships b. Limit or defer examinations and proce- (4) Experiences in previous pregnancies dures, or perform them unobtrusively b. Care practices (1) Interventions and assessments before • First period of reactivity and after birth 1. Begins immediately after birth (2) Behavior of healthcare providers 2. Lasts approximately 30 minutes (3) Care and support received in labor 3. Assessment findings and delivery a. Rapid heart rate and respirations—near (4) Institutional rules and policies upper limits of normal c. Facilitating factors b. Respiratory rales present, disappearing by (1) Skin-to-skin contact 20 minutes of age (2) Breastfeeding c. Behavior—alert, eyes open, may exhibit (3) Visual contact startle, cry, and/or rooting (4) Holding, touching, “getting d. Bowel sounds usually present by 30 min- acquainted” utes after birth; may pass stool 3. Limitations of bonding and attachment 4. Encourage breastfeeding during first period of theories reactivity a. Formation of relationships probably a. Facilitated by infant’s alert, active state evolves out of many experiences rather b. Ameliorates physiologic drop in blood glu- than a single critical event cose at 1 to 1.5 hours after birth b. Little evidence that early separation has permanent effects on mother–infant or • Period of unresponsive sleep parent–child relationships 1. Lasts from 30 minutes to 2 hours after birth c. May lead to judgmental responses among 2. Assessment findings healthcare providers, or guilt among par- a. Heart rate decreases—usually to less than ents, when bonding expectations are not 140 bpm met b. Murmur due to incomplete closure of ductus arteriosus 140 Chapter 5 Midwifery Care of the Newborn

Â Plan of Care for the First Few 2. Vitamin K Days of Life a. Prevention of hemorrhagic disease b. May be administered intramuscularly or • Feeding orally 1. Demand feeding 3. Hepatitis B vaccination a. Indicated for both breast- and bottle-fed a. First dose prior to discharge infants b. Second dose at 1 to 2 months of age b. Most infants will stop sucking and may fall c. Third dose no earlier than 24 weeks of age asleep when full and satisfied 2. Breastfeeding • Health promotion and safety a. Breast-fed infants average 8 to 10 feedings 1. All caregivers should wash hands thoroughly per day before handling infant b. Intake is adequate if the infant seems sat- 2. Follow policies/procedures for infant isfied and wets 4 to 6 diapers per day identification c. Frequent assessment, reassurance, and 3. Follow policies/procedures for infant security anticipatory guidance are essential for 4. Teaching—safety and signs of illness (see Dis- breastfeeding mothers and infants in the charge teaching section in this chapter) first few days of life d. Discourage supplementary bottle feedings Â Discharge Planning to promote development of maternal and infant breastfeeding skills and to ensure • Discharge teaching adequate milk supply 1. Formula feeding 3. Formula feeding a. Use iron-fortified formula a. Formula-fed infants average 6 to 8 feed- b. Clean nipples and bottles thoroughly prior ings per day to use b. Limited stomach capacity c. 1.5 oz every 3 to 4 hours, increasing (1) Infant may take only 20 to 30 mL of gradually formula at initial feedings d. Supplementary water or juice not (2) Most infants should take 60 to 120 mL recommended formula per feeding by the third day of 2. Breastfeeding life a. On demand, at least every 2 to 5 hours c. Demonstrate positioning and burping b. Average 8 to 10 feeds every 24 hours techniques c. 10 to 15 minutes suckling on each side, each feeding • Voiding/Stooling d. Adequate maternal rest and fluid intake 1. Record time and characteristics of first passage e. Sore nipples indicate incorrect positioning of urine and stool or latch-on 2. Stool will progress from meconium to yellow- 3. Voiding/Stooling green a. Bottle-fed infant stools—yellow-green, 3. Absence of voiding for 24 hours is an indica- firm to pasty, straining is normal and not tion for pediatric evaluation necessarily indicative of constipation b. Breast-fed infant stools—yellow-gold, • Skin loose or liquid, frequency varies, stooling 1. Full baths and use of antibacterial soap are with each feed or every other day discouraged c. 4 to 6 wet diapers per day is usually in- 2. “Dry care”—skin is dried and skin folds are dicative of adequate intake wiped clean with gauze 4. Jaundice 3. Warm sponge bath late in first day of life to a. Occurs in more than 50% of newborns; clear blood and meconium more often in breast-fed infants 4. Discourage use of skin lotions, powders, b. Temporary condition, rarely indicative of creams, oils disease c. Usually peaks at 3 to 4 days of life • Medications d. Yellowing of sclera should be evaluated by 1. Gonorrhea/chlamydia prophylaxis pediatric provider a. 0.5% erythromycin ointment 5. Skin b. Should be deferred until after the first pe- a. Sponge bath every day or every other day riod of reactivity b. Tub baths after cord stump falls off Discharge Planning 141

c. Mild, unscented soap • Physical barriers to discharge d. Lotions, oils, and powders are unnecessary 1. Feedings—newborn must demonstrate ad- e. Dry/peeling skin is normal and resolves equate intake of human milk or formula prior spontaneously to discharge f. Diaper rash may be treated with petro- 2. Prematurity leum jelly and air exposure, but notify pe- a. Any newborn less than 37 weeks’ gestation diatric provider if persistent or less than 2500 g should be observed for 6. Cord care minimum of 3 days or in accord with Pedi- a. Apply rubbing alcohol to cord stump sev- atric Department policy eral times per day b. Premature infants must demonstrate abil- b. Diaper should be fastened below cord ity to maintain normal body temperature c. Avoid immersion of cord stump in water outside incubator for 24 hours prior to d. Cord will usually drop off at approximately discharge 2 weeks 3. Neonatal drug withdrawal e. Redness around the cord base, foul odor, a. Newborn should be held for observation or drainage from cord should be reported b. Social work evaluation and referral to drug to pediatric provider treatment are indicated 7. Safety c. Referral to child protective services is indi- a. Infant car seats for every car ride cated if withdrawal symptoms occur or if b. Hand-held carrier vs body carrier—pros newborn’s urine toxicology is positive and cons d. If medication is required to treat with- c. Bottle propping is dangerous due to chok- drawal, newborn must be held until medi- ing risk cation is no longer necessary d. Avoid handling hot liquids while handling e. Newborn should be asymptomatic for 48 newborn to 72 hours e. Avoid exposure to direct sunshine; 4. Congenital abnormalities sunscreens are not necessarily safe for a. Heart murmurs suspected to be patho- newborns logic should be evaluated prior to f. Install smoke detectors discharge g. Avoid exposure to cigarette smoke b. Dislocated hips should be evaluated by h. Infant should sleep in supine or side-lying orthopedic specialist and treatment begun position prior to discharge 8. Expected infant behavior c. Abnormal renal findings on prenatal ul- a. Hiccups are common and do not require trasound should be evaluated prior to treatment discharge b. Sneezing is normal and does not necessar- 5. Infections ily indicate illness a. Sepsis—infant at risk for sepsis should be 9. Signs of illness treated with antibiotics until blood cul- a. Poor feeding, irritability, lethargy, skin tures negative for 72 hours rash, cord problems, vomiting, diarrhea, b. Syphilis—infants with congenital syphi- decreased urine output, rectal tempera- lis or infants of mothers with untreated ture greater than 100°F, or change in in- syphilis should receive spinal tap and be fant’s behavior treated within 10 days with intramuscular b. Emphasize that neonatal infection is not or intravenous penicillin always accompanied by fever c. Pneumonia—infants with pneumonia should be held in hospital for 7 to 14 days • Psychosocial barriers/considerations to discharge for antibiotic treatment 1. Current maternal substance abuse 6. Hyperbilirubinemia 2. Present or historical maternal psychiatric a. Physiologic jaundice illness (1) Not visible in first 24 hours 3. Severe illness or physical disability of the (2) Rises slowly and peaks at day 3 or 4 of mother life 4. History of abuse or neglect of a previous child (3) Total bilirubin peaks at less than 5. Inappropriate maternal behavior 13 mg/dL 6. Homelessness or inadequate living (4) Lab tests reveal predominance of un- arrangements conjugated (indirect) bilirubin (5) Not visible after 10 days 142 Chapter 5 Midwifery Care of the Newborn

b. Possible pathologic jaundice a. Frequency and duration of breast feed- (1) Visible during first 24 hours ings, or frequency and amount of bottle (2) May rise quickly to greater than 5 feedings mg/dL/24 hours b. Number of voids/stools (3) Total bilirubin is greater than 13 c. Present weight and birth weight mg/dL 2. Discharge evaluation should be performed in (4) Greater amounts of conjugated the presence of parents for teaching, answer- (direct) bilirubin ing questions, and providing anticipatory (5) Visible jaundice persists after 1 week guidance c. Labs—serum total bilirubin (STB), blood type, Rh, Coombs • Follow-up care d. Phototherapy, if indicated, may be ar- 1. Pediatric follow-up should be arranged prior ranged through home healthcare agency to discharge e. Infants with elevated bilirubin but with- 2. Factors influencing time of first pediatric visit out hemolytic disease may be discharged a. Medical condition of newborn if outpatient pediatric follow-up can be b. Length of hospital stay arranged c. Experience of mother and family in caring for newborns • Criteria for early discharge d. Size of newborn 1. General criteria e. Mother/family psychosocial factors a. Following uncomplicated birth, most in- f. Adequacy of newborn feeding fants may be discharged at 12–24 hours after birth depending on hospital policy Â Newborn Assessment b. Joint decision by midwife, pediatric provider, and family • History—see Immediate Care and Assessment of c. Uncomplicated antepartum, intrapartum, the Healthy Newborn section and postpartum course d. Early discharge increases importance of • Physical examination patient and family education to assess 1. General newborn a. Whole e. Adequate support for mother at home, (1) Proportions including home healthcare referral (2) Symmetry 2. Neonatal criteria (3) Facies a. Uncomplicated vaginal delivery (4) Gestational age (approximate) b. Full-term infant with adequate growth b. Skin (2500 to 4500 g) (1) Color c. Normal findings on neonatal examination (2) Subcutaneous tissue d. May be minimum 6-hour hospitalization (3) Imperfections (bands and birthmarks) but at least sufficient time under provider (4) Vernix and lanugo care to demonstrate: (5) Cysts and masses (1) Thermal homeostasis c. Neuromuscular (2) Ability to feed (1) Movements e. Normal laboratory results confirmed (2) Responses 3. Maternal criteria (3) Tone (flexor) a. Demonstrated ability with chosen feeding 2. Head and neck method a. Head b. Demonstrated ability with cord care (1) Shape c. Demonstrated ability to assess newborn’s (2) Circumference temperature with thermometer (3) Molding d. Verbalizes understanding of signs of new- (4) Swellings born well-being and illness (5) Depressions (6) Occipital overhang • Discharge evaluation b. Fontanelles, sutures 1. Complete physical examination with emphasis (1) Size on the following: (2) Tension c. Eyes (1) Size Newborn Assessment 143

(2) Separation b. Hands—digits; polydactyly, syndactyly, (3) Cataracts webbing, overlapping, shape and texture; d. Ears “fisting” (1) Placement c. Feet—degree of flexion, shape, position (2) Complexity d. Neck—rotation (3) Preauricular tags e. Joints—normal range of motion e. Mouth f. Long bone fractures—distortion, swelling, (1) Symmetry crepitus (2) Size 9. Spine (3) Clefts a. Symmetry f. Neck b. Scoliosis (1) Swellings c. Sinuses (2) Fistulas 3. Chest • Gestational age assessment a. Inspect for deformities (nipples, clavicles, 1. Dubowitz (detailed assessment of gestational sternum) age) and Ballard (abbreviated version of b. Observe respiratory function with Dubowitz) scales abdomen a. Estimation of gestational age and maturity c. Palpate—breast bud size; clavicle for crep- based on observation and examination— itus and/or swelling score for 40-week infant total equals 40 4. Lungs and respiration b. Elements include posture and tone, and a. Retraction characteristics of skin, lanugo, plantar sur- b. Grunt face, breast tissue, eyes/ears, and genitals c. Quality of breath sounds 2. Posture and tone—premature infant generally 5. Heart and circulation demonstrates extended posture, less tone, and a. Rate less resistance to flexion of extremities b. Rhythm 3. Skin—premature infant has redder/pinker, c. Murmurs—usually present for 1–2 days translucent skin; postmature infant has after birth until ductus arteriosus closes cracked, wrinkled skin d. Sounds 4. Lanugo is sparse to absent in the postmature 6. Abdomen or very premature infant and is most abundant a. Musculature in midterm infant (28 to 30 weeks) b. Bowel sounds 5. Plantar surface c. Cord vessels—number and type a. Assessed by length of foot from heel to tip d. Distension of great toe in the premature infant e. Scaphoid shape b. Creases appear by 28 to 30 weeks of gesta- f. Masses tion and cover the entire surface at term g. Liver edge may be palpable at 2–3 cm be- 6. Breast tissue and areola—progressive develop- low right costal margin ment throughout gestation h. Normal spleen and kidneys are not easily a. Preterm—flat areola with no palpable felt breast bud i. Femoral pulses are felt when the infant is b. Term infant—raised areola with 3 to 4 mm quiet palpable breast bud 7. Genitalia and anus 7. Eye/ear a. Placement a. Eyelids are fused in very premature b. Identify ambiguous genitalia neonate c. Scrotum—size, skin is wrinkled; deter- b. More mature infants will exhibit more car- mine if testes are descended tilaginous ear tissue that exhibits greater d. Phallus—size, placement of urethra firmness and recoil when flexed e. Labia—palpate for masses; identify all 8. Male genitalia—increasing rugation of scro- structures and determine patency of vagi- tum and descent of testes with advancing ges- nal orifice tational age f. Anus—determine patency and relative po- 9. Female genitalia—increasing development of sition to other genital structures labia majora and decreasing prominence of 8. Musculoskeletal clitoris and labia minora with advancing gesta- a. Posture tional age 144 Chapter 5 Midwifery Care of the Newborn

10. Anterior vascular capsule of ocular lens—more h. Darwinian tubercule—small nodule on prominent vasculature at early gestational upper helix of ear ages i. Digital anomalies—curved, webbed, or bent fingers • Measurements j. Transverse palmar crease 1. Weight k. Shawl scrotum a. Normal weight for a term newborn is 2501 l. Redundant umbilicus to 4000 g m. Widespread or supernumerary nipples b. Less-than-normal birth weight— definitions • Neurologic examination (1) Extremely low birth weight—less than 1. Level of alertness 1000 g a. Most sensitive of all neurologic functions (2) Very low birth weight—1000–1500 g b. Varies depending on gestational age, time (3) Low birth weight—1501–2500 g of last feeding, sleep patterns, recent stim- c. Usual growth patterns uli, and recent experiences (1) Infants typically lose 10 to 15% of c. Findings associated with level of alertness birth weight in first 3 days of life (1) Response to arousal attempts (e.g., (2) Should regain birth weight by 10 to 14 gentle shaking, sound, light) days of age (2) Level and character of motility (3) Double birth weight by 4 to 6 months 2. Neuromotor findings of age a. Tone and posture (4) Triple birth weight by 12 months of b. Motility and power age c. Tendon reflexes—pectoralis major, bra- 2. Length chioradialis, patellar, achilles a. Most accurately measured by placing head d. Plantar response—flexion or extension of against a firm surface, extending legs, then toes marking the surface e. Eyes—red reflex, pupillary reflex, doll’s eye b. Normal length for a term newborn is 48 to reflex, blink reflex 53 cm 3. Assess for normal, absent, diminished or exag- 3. Head circumference gerated reflexes—abnormal reflexes suggest a. Measured from the occiput around head nervous system depression, spinal lesion, or and above eyebrows central nervous system disorder or lesion b. Normal head circumference for a term 4. Primary neonatal reflexes (Volpe, 2008) newborn is 33 to 35 cm a. Palmar grasp 4. Chest circumference (1) Newborn grasps object or finger a. Measured under armpits across nipple placed on his/her palm line (2) Typically disappears by 2 months of b. Normal chest circumference is 30 to age 33 cm and 2 to 3 cm less than head b. Tonic neck response circumference (1) Elicited by rotation of the head to one 5. Be aware of genetic pool of parents, i.e., one or side both of small stature (2) Newborn extends arm on the side to which the head is rotated and • Assessment for birth defects flexes the contralateral arm (“fencing 1. Minor malformations are relatively common, posture”) but three or more minor malformations on (3) Typically disappears by 7 months of physical examination is suggestive of a major age underlying condition c. Moro reflex 2. Minor malformations (1) “Startle” response, evidenced by ab- a. Large fontanelles duction and extension of arms with b. Epicanthic eye fold hands open and thumb and index fin- c. Hair whorls ger semiflexed to form a C d. Widow’s peak (2) Elicited by jarring examination table, e. Low posterior hair line allowing the infant to fall backward f. Preauricular skin tags or pits onto the examiner’s hand, or making a g. Minor ear anomalies—low-set, rotated, loud noise protruding Primary Care of the Newborn for the First 6 Weeks 145

(3) Typically disappears by 6 months of • Newborn behavior age 1. Sleep-wake states as classified by Brazelton d. Placing and stepping (“walking”) a. Quiet sleep (1) Elicited by holding the infant upright b. Active sleep and placing soles of feet in contact c. Drowsy with flat surface or table edge d. Quiet alert (2) Typically disappears by 4 weeks of age e. Active alert f. Crying • Metabolic screening 2. Alert state 1. No federal guidelines; requirements vary state a. Determine infant’s ability to feed and in- to state teract with environment 2. Metabolic screening tests mandated in most b. Comprises approximately 15% of daytime states, e.g.: hours a. Phenylketonuria 3. Crying b. Biotinidase deficiency a. May express need for feeding, holding, c. Congenital adrenal hyperplasia stimulation, or sleep d. Congenital hypothyroidism b. May be indicative of pain e. Cystic fibrosis c. Parental responsiveness to crying does f. Galactosemia not promote “spoiling” of infant—re- g. Homocystinuria sponsiveness is essential to newborn’s h. Branched-chain ketoaciduria development i. Sickle cell disease 4. Sleeping j. Tyrosinemia a. Infant may exhibit varying respiratory pat- 3. Timing of metabolic screening terns while sleeping e.g., decreased depth a. Generally, after 24 hours of age—allowing and rate or periodic breathing (intermit- time for feeding to be established and ac- tent cessation of breathing for up to 10 cumulation of toxic metabolites if disease seconds) is present b. Normal infants sleep up to 60% of the time b. Preferably 48 to 72 hours of age c. Recommended repeat screening at 2 to • Sensory capabilities 4-week pediatric visit 1. Sensory threshold—level of tolerance for d. Law may mandate screening before dis- stimuli within which the infant can respond charge—for early discharge, repeat screen- appropriately ing must be done a. Infant may become fatigued or stressed when overstimulated; signs of stress and Â Primary Care of the Newborn fatigue include: for the First 6 Weeks (1) Color changes (2) Irregular respiration • Well child surveillance (3) Irritability or lethargy 1. All newborns should have at least two physical (4) Vomiting examinations before discharge b. Varies significantly among individuals; 2. Well child visit markedly low in premature or neurologi- a. Within 3 to 5 days for early-discharged cally impaired newborns newborns 2. Visual capabilities b. Within 10 to 14 days for newborns held 48 a. Normal term infant can visually fix and hours track objects c. Purpose—reexamine newborn, review b. Sharp focus limited to distance of 10 to 12 teaching, perform metabolic screening inches d. Assessment includes c. Preference for striped patterns and strong (1) Review of maternal, perinatal, and contrasts newborn history d. Limited color perception (2) Observation of parents and assess- e. Ability to recognize mother visually and ment of family adjustment respond to facial expressions within the (3) Newborn interval history, including first few weeks of life feeding, behavior, voiding/stooling 3. Newborns can detect and discriminate odors (4) Physical examination 4. Taste capabilities e. Schedule follow-up visits 146 Chapter 5 Midwifery Care of the Newborn

a. Newborns react strongly to variations in 2. Development of differentiation—ability to dis- taste criminate between self and other b. Preference for sweet 3. Ability to elicit care giving is essential to early 5. Hearing is acute, with ability to localize sounds development and preference for mother’s voice 4. Secure attachment depends on caregivers’: 6. Touch—sensitive to light touch, as demon- a. Emotional availability strated by reflex responses b. Sensitivity and stimulation c. Appropriate response to infant cues • Regulation of behavior d. Consistency 1. Ability to respond appropriately to stimuli and 5. In the first year of life, securely attached in- maintain behavioral states fants will venture out and return to mother 2. Full-term infants should demonstrate smooth 6. Results of insecure attachment transition between states from sleep to active a. Anxious or unable to cope with changes or alertness; consistently abrupt or unpredictable distance from mother changes are a cause for concern b. More negative infant behavior 3. Ability to maintain active alert state varies c. Avoidance/detachment among individuals—some have difficulty be- d. Research suggests long-term impair- coming or remaining alert, while irritable in- ment, including school problems and fants progress rapidly from alertness to crying delinquency 4. Overstimulated infants may require “time- 7. Counseling or parenting classes may be help- out”; relative isolation from stimuli and time ful when mothers/caregivers are experiencing to recover problems in forming secure attachment 5. Organization—ability to integrate physiologic and behavioral systems in response to the • Circumcision environment without disruption in state or 1. Increased prevalence in United States during physiologic functions 1950s a. Maintenance of stable vital signs 2. Significant role of cultural, religious, and fam- b. Smooth state transitions ily traditions c. Coordination of movements and re- 3. Medical complications are rare but serious; sponses in interacting with environment include bleeding, infection, and inappropriate d. Consolable with ability for self-consolation operative result (frequently characterized by hand-to- 4. Controversial impact on sexual and psycho- mouth movements) logical functioning; no clear evidence e. Habituation—ability to block out noxious 5. Unclear evidence as to risks/benefits; routine stimuli circumcision for medical reasons is no longer recommended • Developmental milestones in first 6 weeks as mea- 6. Provide pain control if family chooses sured by Denver II circumcision 1. Personal/social skills—spontaneous and re- 7. Care of circumcised infant sponsive smiling, attentiveness to a face a. Apply petroleum jelly gauze strip to pre- 2. Visual tracking—follows dangling object from vent adhesion of tissue to diaper midline through 45° b. Continue to use petroleum jelly on af- 3. Spontaneous vocalization fected tissue until healed 4. Response to sound of bell c. Notify care provider if bleeding, exudate, 5. Gross motor—lifting head momentarily and swelling, or inability to void occur symmetrical body movements 8. Uncircumcised infant a. Foreskin should separate and become • Psychological tasks of early infancy as defined by freely mobile by 4 to 7 years of age Erikson b. Never forcefully retract the foreskin 1. Development of basic trust c. Infant hygiene—“only clean what can be a. Birth through 12 to 18 months seen” b. Definition—belief that world is a place d. As the child matures, he should be taught where people and things can be relied to retract the foreskin and clean upon and needs and wishes will be met c. Essential for formation of human attach- • Nonnutritive sucking ments throughout life 1. Thumb sucking and use of pacifiers subject to mother/family preferences and attitudes Common Variations from Normal Newborn Findings 147

2. Common behavior in utero 2. Treatment 3. Infant may use nonnutritive sucking to regu- a. Massage—apply gentle, firm pressure in a late behavior state or self-console circular motion on the lateral aspect of the 4. Avoid nose adjacent to inner canthus of eye a. Use of empty bottle for nonnutritive suck- b. Clear drainage with cotton ball moistened ing (promotes ingestion of air, dental car- with warm water, proceeding from inner ies, and may contribute to otitis) to outer canthus b. Placing pacifier on string around baby’s c. Repeat treatment 3 to 4 times per day neck c. Prolonged use of and serious dependence • Dacryocystitis on pacifiers 1. Definition—acute infection of lacrimal ducts 2. Presentation—purulent discharge, swelling, Â Common Variations from tenderness adjacent to inner canthus of eye Normal Newborn Findings 3. Treatment a. Same hygiene routine as described for ob- • Jaundice structed lacrimal ducts 1. Incidence—up to 50% of newborns b. Aseptic technique to prevent cross- 2. Physiologic vs pathologic jaundice contamination a. Physiologic jaundice does not occur c. Topical or systemic antibiotics are within first 24 hours of life indicated b. Total serum bilirubin concentrations increasing by more than 5 mg/dL per day • Skin problems indicate pathologic jaundice 1. Cradle cap c. Physiologic jaundice rarely results in total a. Definition—dermatitis resulting from ac- serum bilirubin concentrations greater cumulation of sebum on scalp than 15 mg/dL b. Presentation—characteristic yellow, crust- d. Direct serum bilirubin levels greater than ing patches on anterior scalp, often in area 1.5 mg/dL indicate pathologic jaundice of anterior fontanelle 3. More common and slower to resolve in breast- c. Treatment fed infants (1) Vigorous cleansing with mild sham- 4. Can be detected by blanching skin of nose, poo and washcloth palms, or soles of feet—if jaundiced, skin will (2) Apply baby oil to area 30 minutes blanch yellow prior to shampooing 5. Treatment (3) Rub affected area with dry washcloth a. Supplementation of breast-fed infants gently but firmly to remove crusting with oral glucose water is not helpful and (4) If severe, antiseborrheic shampoo may be harmful may be indicated b. Frequent feeding to stimulate GI 2. Diaper dermatitis elimination a. Definition—general term for a variety of c. Management algorithm (values reflect to- skin conditions that can occur in the dia- tal serum bilirubin concentrations) per area (1) Consider phototherapy for values of b. Primary—caused by exposure to moisture 12 to 17 mg/dL and friction (2) Phototherapy indicated for values of c. Secondary 15 to 20 mg/dL (1) Caused by colonization of affected (3) Exchange transfusion indicated for area by pathogen; most commonly values of 20 to 25 mg/dL Candida albicans (4) Treatment thresholds are lower at ear- (2) Presentation—“fire-engine red” ery- lier ages (24 to 48 hours after birth) thema, circumscribed pustulovesicu- d. Phototherapy may be indicated; some lar lesions, often with satellite lesions sources recommend exposing newborn to d. Treatment indirect sunlight for short periods several (1) Change diapers frequently times per day (2) Avoid use of baby wipes (3) Rinse area with tepid water after ev- • Obstructed lacrimal ducts ery voiding; use tepid water and mild 1. Incidence—50% of newborns will exhibit ex- soap after stooling cessive tearing and mucoid discharge from (4) Clean and dry skin thoroughly eyes 148 Chapter 5 Midwifery Care of the Newborn

(5) Allow exposure of skin to air, espe- 3. No proven organic basis; suggested but un- cially before reapplying diaper proved causative factors include: (6) Some infants are sensitive to irritants a. Overfeeding, especially in bottle-fed in disposable diapers; change brands infants or use cloth diapers b. Allergy to constituents of formula or (7) For infants with diarrhea, apply zinc breastfeeding mother’s diet (milk products oxide ointment to clean, dry skin to often suggested) provide a barrier c. Anxiety in primary caregiver or tension in (8) Severe irritation may be treated with household; possibly symptomatic rather 1% topical hydrocortisone than etiologic (9) Nystatin topical cream, applied at d. Immaturity of digestive system each diaper change, for Candida albi- 4. Treatment cans dermatitis a. Attempt to identify factors associated with colic episodes for the individual infant • Thrush b. Correct overfeeding 1. Definition—oral fungal infection usually c. Trial elimination of milk products from caused by Candida albicans breastfeeding mother’s diet 2. Peak incidence around second week of life (1) Efficacy is unknown; anecdotally ef- 3. Often occurs after antibiotic therapy fective in many cases 4. Presentation—characteristic white patches on (2) If bovine allergens are implicated, a the buccal mucosa, gums, tongue, and/or pal- trial longer than 1 week is necessary to ate; lesions may be friable clear mother’s system 5. May cause feeding difficulty if extensive (3) Maternal calcium supplementation is 6. Treatment suggested with this approach a. Nystatin suspension orally 4 times a day d. Some infants respond to warmth, wrap- for 1 week ping in a blanket, limitation of stimuli, b. Instill one dropper-full into each buccal rhythmic soothing motion, gentle repeti- pocket tive massage, or soft monotonous music c. “Paint” lesions with cotton-tipped e. Probably most important factor is sup- applicator portive care for parents, including reassur- d. Bottle-fed infants—boil nipples after use ance and respite opportunities e. Breast-fed infants—treat mother’s f. As a last resort for exhausted parents, in- nipples simultaneously with topical an- fant may be positioned safely and left to tifungal agents (nystatin, miconazole, cry for limited periods of time clotrimazole) Â Deviations from Normal • Regurgitation 1. Definition—effortless “spitting up” of small • Danger signs of neonatal morbidity amount of formula or breast milk 1. Central nervous system signs 2. Exacerbated by excessive swallowing of air, re- a. Lethargy sulting from underfeeding or delayed feeding b. High-pitched cry and prolonged crying, improper positioning, c. Jitteriness sucking on empty formula bottle d. Abnormal eye movement 3. Treatment e. Seizure activity a. Normal self-limiting condition, no treat- f. Abnormal fontanelle size or bulging ment necessary fontanelles b. May be reduced if infant is positioned sit- 2. Respiratory signs ting upright at 50 to 60-degree angle for 30 a. Apnea of more than 15 seconds accompa- to 60 minutes after feeding nied by bradycardia or cyanosis b. Tachypnea • Colic c. Nasal flaring, expiratory grunting, and/or 1. Definition—sudden, loud, and/or continu- chest retractions ous unexplained crying often accompanied by d. Persistent rales and/or rhonchi flushed facies, mild abdominal distension, ad- e. Asynchronous breathing movements duction of legs, or clenched fists 3. Cardiovascular signs 2. Affects 10% of infants a. Abnormal rate and rhythm b. Murmurs Deviations from Normal 149

c. Changes in blood pressure 2. Symmetric growth restriction d. Marked differential between upper and a. Results from early and prolonged insult(s) lower extremity blood pressure b. Associated with decreased brain size and e. Alterations and/or differentials in pulses mental retardation f. Changes in perfusion and skin color c. Growth restriction continues after birth 4. Gastrointestinal signs 3. Asymmetric growth restriction a. Refusal to feed a. Results from insult(s) late in pregnancy b. Absent or uncoordinated feeding reflexes b. Head circumference is near normal for c. Vomiting gestational age d. Abdominal distension c. Rapid postnatal growth and development e. Changes in stool patterns with normal cognitive development 5. Genitourinary signs 4. Maternal factors associated with growth a. Hematuria restriction b. Absence of urine or failure to pass urine a. Obstetric—history of infertility, history of 6. Metabolic alterations abortions, grand multiparity, pregnancy- a. Hypoglycemia induced hypertension b. Hypocalcemia b. Medical—heart disease, renal disease, hy- c. Hyperbilirubinemia and jaundice, espe- pertension, sickle cell disease, phenylketo- cially jaundice occurring within the first 24 nuria, diabetes hours of life c. Psychosocial—malnutrition, low socioeco- 7. Fluid balance alterations nomic status, extremes of maternal age, a. Decreased urine output poor prenatal care, substance abuse b. 5–15% weight loss in one day c. Dry mucous membranes • Postterm infants d. Sunken fontanelles 1. Definition—born after 42 completed weeks’ e. Poor skin turgor gestation f. Increased hematocrit 2. Associated complications 8. Temperature instability a. Meconium aspiration (1) Physical barrier to gas exchange • Preterm infants (2) Causes chemical irritation and thick- 1. Definition—infants born before 37 completed ening of the alveolar walls weeks of gestation (3) Vasoconstriction/vasospasm may 2. Associated complications cause pulmonary hypertension and a. Respiratory complications persistent fetal circulation b. Necrotizing enterocolitis b. Hypoglycemia c. Intraventricular hemorrhage c. Polycythemia d. Hypothermia d. Hypothermia e. Hypoglycemia 3. Associated maternal and fetal factors f. Infection a. Maternal—primigravid, grand multiparity, g. Hyperbilirubinemia previous postterm delivery 3. Maternal factors associated with prematurity b. Fetal—anencephaly, trisomies a. Obstetric—uterine malformation, multiple gestation, incompetent cervix, • Large for gestational age infants premature rupture of membranes, 1. Definition—birth weight above 90th percentile pregnancy-induced hypertension, or two standard deviations above the mean; placenta previa, history of previous pre- sometimes defined as birth weight above 4000 term birth, isoimmunization or 4500 g b. Medical—diabetes, hypertension, urinary 2. Associated complications tract infection, other acute illness a. Birth injuries, including fractures and in- c. Psychosocial—poor prenatal care, low so- tracranial hemorrhage cioeconomic status, malnutrition, adoles- b. Hypoglycemia (resulting from increased cent pregnancy, substance abuse activity and hypertrophy of pancreatic is- let cells) • Small for gestational age infants c. Polycythemia 1. Definition—birth weight below 10th percentile d. Perinatal asphyxia or two standard deviations below mean for 3. Maternal factors associated with excessive fe- gestational age tal growth 150 Chapter 5 Midwifery Care of the Newborn

a. Gestational diabetes b. Listeria b. Genetic predisposition (1) Presentation—diffuse papular rash on c. Excessive maternal weight gain during trunk and pharynx, respiratory dis- pregnancy tress, cyanosis, sepsis 4. Infants of diabetic mothers (IDM) (2) Etiology—maternal colonization, a. Chronic or severe maternal diabetes with transmitted to neonate during labor vascular changes more likely to result in and delivery growth restriction c. Escherichia coli b. Gestational diabetes and hyperglycemia (1) Major cause of neonatal meningitis more likely to result in excessive fetal and sepsis growth (2) Etiology—maternal colonization, c. Associated with congenital anomalies, in- transmitted to neonate during labor cluding central nervous system anomalies, and delivery congenital heart defects, and tracheo- d. Neissieria gonorrhoeae esophageal fistula (1) Pathogenic for ophthalmia neonatorium • Neonatal infection (2) May cause blindness if untreated 1. Signs of infection in the newborn (3) Prophylaxis—administration of silver a. Often subtle and nonspecific nitrate or erythromycin ointment to b. Early signs—lethargy, refusal to feed, vom- eyes after birth iting, temperature instability (4) Rarely, may invade joint capsules c. May show subtle changes in color—cyano- causing septic arthritis sis, pallor, mottling e. Tuberculosis d. May be related to involved organ system(s) (1) Congenital disease is rare unless (1) CNS infections—jitteriness, seizures mother has untreated, advanced (2) Pulmonary infections—respiratory disease distress, apnea (2) Primarily affects newborn liver when (3) Intestinal infections—diarrhea acquired before birth 2. Signs of chronic intrauterine infection (3) Separation of newborn from mother a. Growth retardation is unnecessary if mother has negative b. Microcephaly chest radiograph, negative sputum c. Hepatosplenomegaly culture, and is receiving treatment 3. Sepsis 5. Viral and protozoan infections a. Increased susceptibility due to immature a. Toxoplasmosis immune function (1) Associated with raw meat and infected b. Evaluation includes blood and CSF cul- feces, especially cat tures, CBC with differential, IgM titer, (2) Mother is often asymptomatic chest radiograph, and toxoplasmosis, (3) Signs of infection in the newborn rubella, cytomegalovirus, and herpes include microcephaly, cerebral calcifi- screening cations, chorioretinitis, hepatospleno- 4. Bacterial infections megaly, and jaundice a. Group B b-hemolytic streptococcus (GBS) (4) Treatment limits further disease but (1) Most common pathogen in neonatal does not correct damage to the central infections nervous system (2) Etiology—maternal colonization, b. Syphilis transmitted to neonate during labor (1) Signs of infection in the newborn in- and delivery clude intrauterine growth restriction (3) Preterm newborns at highest risk (IUGR), ascites, rhinitis, jaundice, (4) Early-onset GBS disease—develops anemia within first 24 hours of life, character- (2) Spontaneous abortion, stillbirth, or ized by respiratory involvement, may newborn demise occur in 40% of cases be fatal when mother is untreated; another (5) Late-onset GBS disease—onset usu- 40% will result in congenital syphilis ally after second week of life, charac- (3) Congenital syphilis may result in mul- terized by CNS involvement, rarely tisystem organ damage and/or death fatal, but may result in permanent neurologic damage Deviations from Normal 151 c. Rubella (3) May result in prematurity, growth re- (1) Infection in utero may result in IUGR, striction, and/or microcephaly cardiac anomalies, deafness, blind- (4) Opportunistic infection usually mani- ness, and/or mental retardation fests within the first months of life (2) Effects depend on gestational age at transmission and duration of • Plexus injuries—prognosis is good; 88–92% of af- infection fected infants recover fully within first year of life d. Cytomegalovirus (CMV) 1. Thought to result from lateral traction on (1) No effective means of treatment or shoulder or head during delivery; some evi- prevention dence of intrauterine effect also exists (2) Effects of congenital CMV infec- 2. Erb’s palsy tion—30% incidence of death in in- a. Accounts for 90% of all plexus injuries fancy, 90% of survivors will have CNS, b. Involves upper part of the plexus (C5 visual, and/or auditory damage through C7 and occasionally C4) e. Herpes c. Shoulder and upper arm are affected (1) Transmission typically occurs during d. Decreased biceps reflex is present intrapartum period; prenatal infection e. When C4 is involved, diaphragmatic dys- is rare function is present (2) Newborns are susceptible to systemic 3. Total palsy disease, which may involve hepatitis, a. Accounts for 8–9% of all plexus injuries pneumonia, encephalitis, and/or dis- b. Diffuse plexus involvement (C5 to T1) seminated intravascular coagulopathy c. Upper arm, lower arm, and hand are (3) Primary maternal infection is associ- affected ated with 50% newborn mortality rate d. Biceps and triceps reflexes are decreased and high rates of permanent neuro- 4. Klumpke’s paralysis logic damage a. Accounts for less than 2% of all plexus (4) Recurrent maternal infection rarely injuries results in severe systemic disease b. Involves C8 to T1 f. Hepatitis B c. Lower arm and hand are affected (1) Often results in prematurity and low 5. Associated injuries—clavicle fracture, hu- birth weight merus fracture, shoulder dislocation, facial (2) Onset of disease occurs 4 to 6 weeks nerve injury after birth and is marked by poor 6. Management usually consists initially of limit- feeding, jaundice, and hepatomegaly ing movement of the affected extremity, then (3) Most infants infected perinatally dem- gradual introduction of gentle range-of- onstrate carrier state without acute motion exercises disease g. Chlamydia • Neonatal fractures (1) Most common cause of blindness 1. Fracture of the clavicle—not a significant new- worldwide born fracture (2) Intrapartum transmission may result a. Most common neonatal fracture in conjunctivitis, pneumonia, and/or b. Signs—hematoma, crepitus, asymmetric otitis media tone/movement of upper extremities (3) Chlamydial conjunctivitis is not pre- c. Sometimes associated with plexus injuries vented by ocular administration of 2. Fracture of humerus or femur—significant silver nitrate; erythromycin ophthal- fractures, may be nosocomial mic ointment is preferred a. Rare; usually associated with breech h. Human immunodeficiency virus (HIV) deliveries and acquired immune deficiency syn- b. Ecchymosis, hematoma, or hemorrhage drome (AIDS) may occur at fracture site (1) Maternal antiretroviral therapy signifi- 3. Skull fracture cantly reduces vertical transmission; a. Rare; may be associated with forceps elective cesarean section may also delivery reduce vertical transmission b. Linear fracture—usually benign, resolves (2) Can be transmitted via breast milk without treatment 152 Chapter 5 Midwifery Care of the Newborn

c. Depressed fracture—may be associated b. May result in withdrawal syndrome in the with seizures and/or permanent neuro- neonate characterized by irritability, trem- logic injury ors, tachypnea, tachycardia, poor feeding d. Signs—cephalohematoma, palpable de- 2. Cocaine abuse pression in bone a. Fetal/neonatal effects—prematurity, low birth weight, IUGR, genitourinary abnor- • Infants with hemolytic disease malities, seizures, congenital heart dis- 1. Definition—destruction of red blood cells re- ease, irritability, frantic or poor feeding sulting in hyperbilirubinemia and jaundice b. May result in long-term behavioral 2. Causes—maternal antibodies, enzymatic dis- impairment orders, infections 3. Opiate abuse 3. Rh incompatibility a. Minimal long-term effects compared to a. Occurs when mother is Rh negative and cocaine and alcohol; primarily affects im- fetus is Rh positive mediate neonatal period b. Positive result on direct Coombs’ test indi- b. Abstinence syndrome (opiate withdrawal) cates presence of maternal antibodies (1) Onset shortly after birth c. May necessitate exchange transfusion (2) CNS signs—irritability, tremors, high- 4. ABO incompatibility pitched cry, hyperstimulability, pos- a. Occurs when mother is serologic type O sible seizure activity and fetus is type A or B; infrequently when (3) Other signs—tachypnea, tachycardia, mother is type A and fetus is type B poor or disorganized feeding, hyper- b. Very rare incidence of hydrops or stillbirth thermia, vasomotor instability c. May result in neonatal jaundice; rarely (4) Care is primarily supportive causes severe hemolysis or anemia 4. Marijuana abuse a. Little or no evidence for teratogenic effects • Hyperbilirubinemia and severe jaundice b. Possible newborn behavioral effects—fine 1. Associated with many neonatal complications, tremor, prolonged startle response, irrita- including hemolytic disease, prematurity, bility, poor habituation to visual stimuli impaired hepatic function, sepsis, metabolic c. No behavioral effects demonstrated to disorders, hematomas, impaired intestinal persist beyond infancy function, and others 5. Prescription drugs of abuse potential 2. Kernicterus a. Amphetamines a. Encephalopathy caused by deposition of (1) Fetal/neonatal effects—genitourinary, bilirubin in brain cells cardiac, and/or central nervous sys- b. Classic signs—lethargy, diminished re- tem abnormalities, behavioral state flexes, hypotonia, and seizures disorganization c. Contributing factors—prematurity, hypo- (2) May result in long-term learning thermia, asphyxia, acidosis, sepsis disabilities d. Complications include hearing im- b. Benzodiazepines—fetal/neonatal effects pairment, cerebral palsy, and mental include hypotonia, hypothermia, low Ap- retardation gar scores, respiratory depression, poor 3. Phototherapy feeding, possible association with midline a. Oxidizes unconjugated bilirubin in the cleft defects skin, rendering it water soluble and facilitating elimination • Congenital anomalies b. Precautions 1. Central nervous system anomalies (1) Protect infant’s eyes from high- a. Spina bifida occulta intensity light (1) Absent or incomplete closure of one (2) Monitor fluid status and temperature or more vertebral arches (2) Dimple or hair tuft may be present • Infants affected by maternal substance abuse over site 1. Fetal alcohol syndrome (3) Often asymptomatic without requir- a. Fetal/neonatal effects—microcephaly, fa- ing treatment cial abnormalities, cardiac defects, malfor- b. Meningocele/myelomeningocele mation of joints, failure to thrive, mental (1) Meningocele—extrusion of meninges retardation and cerebrospinal fluid (CSF) through defect in vertebral column Deviations from Normal 153

(2) Myelomeningocele—meningocele b. Anomalies resulting in cyanotic heart with extrusion of spinal cord disease (3) Surgical repair is necessary to prevent (1) Tetralogy of Fallot—pulmonary steno- rupture and infection sis, ventricular septal defect, over- (4) Myelomeningocele results in loss of riding aorta, and right ventricular sensory and motor function below the hypertrophy level of the defect (2) Transposition of the great vessels— c. Anencephaly aorta arises from right ventricle and (1) Congenital absence of cranial vault pulmonary artery arises from left ven- and underlying brain tissue tricle, resulting in circulatory bypass (2) Newborn may manifest heart rate and of lungs and circulation of unoxygen- respiration but will die within a few ated blood to the body hours after birth (3) Tricuspid atresia—results in no direct d. Hydrocephalus communication between right atrium (1) Abnormal accumulation of cerebro- and right ventricle; further resulting spinal fluid in ventricles of the brain in hypoplastic right ventricle and en- (2) Signs—increased head circumference, larged left ventricle separation of cranial sutures, bulging (4) Truncus arteriosus—failure of embry- tense fontanelles, high pitched cry, onic structure to divide into aorta and and downward deviation of eyes (“set- pulmonary artery ting sun sign”) (5) Surgery is more complicated, with (3) Surgical treatment involves placement generally poorer outcomes (except of a shunt to drain excess fluid Tetralogy of Fallot) 2. Respiratory anomalies 4. Gastrointestinal anomalies a. Choanal atresia a. Cleft lip and palate (1) Definition—congenital blockage of (1) Definition—incomplete fusion posterior nasal passages of lip and palate during prenatal (2) Respiratory distress will be evident at development birth if both nares are blocked (2) May interfere with feeding and weight (3) Treatment includes respiratory sup- gain port and surgical repair (3) Surgical repair usually results in good b. Diaphragmatic hernia cosmetic and functional results (1) Definition—defect of diaphragm, b. Esophageal atresia and tracheoesophageal allowing herniation of abdominal fistula contents into thoracic cavity and dis- (1) Definition—abnormal development placement of heart and lung tissue of trachea and esophagus, resulting (2) Presentation—respiratory distress and in “blind pouch” esophagus and/or scaphoid abdomen apparent at birth communication between the two (3) Treatment is surgical repair structures c. Pulmonary hypoplasia/agenesis (2) Presentation—copious drooling, poor (1) Definition—underdevelopment or feeding with reflux, acute respiratory absence of one or both lungs distress and cyanosis with feeding (2) Strong association with other (3) Repaired surgically, with good anomalies prognosis (3) Rare condition with high mortality c. Pyloric stenosis rate (1) Definition—obstruction of pylorus (4) Presentation—acute respiratory dis- (distal opening of stomach) tress with thoracic asymmetry (2) Affects males three to four times more 3. Cardiovascular anomalies often than females a. Anomalies resulting in acyanotic heart (3) Presentation—vomiting, visible gas- disease tric peristalsis, constipation (1) Atrial septal defect, ventricular septal (4) Repaired surgically, with good defect, patent ductus arteriosus, and prognosis coarctation of the aorta d. Omphalocele (2) Surgical repair required (1) Definition—defect of abdominal wall (3) Prognosis is usually good for isolated with herniation of abdominal viscera defects through umbilical ring 154 Chapter 5 Midwifery Care of the Newborn

(2) Protruding abdominal viscera usually 6. Musculoskeletal anomalies covered by membrane a. Congenital hip dysplasia (3) Frequently associated with other (1) Definition—abnormal development anomalies of the acetabulum, resulting in dislo- (4) Repaired surgically; prognosis de- cation of femoral head pends on extent of lesion and nature (2) Presentation—asymmetry of gluteal and extent of associated anomalies folds, positive Ortolani sign e. Gastroschisis (3) Treatment—reduction and stabiliza- (1) Definition—defect of abdominal wall tion of femoral head into acetabulum and evisceration of abdominal organs to allow development of stable hip (2) Rarely associated with other capsule anomalies (4) Stabilization is accomplished by use (3) Management at birth—cover eviscer- of Frejka splint or Pavlik harness ated organs with sterile gauze moist- b. Talipes equinovarus ened with sterile saline solution (1) Definition—congenital deformity of (4) No oral intake until after repair; IV ankle and foot therapy for fluid and electrolyte (2) Orthopedic treatment involves appli- maintenance cation of splints or successive plaster (5) Repair may require several surgeries; casts to correct position of foot and prognosis depends on extent of lesion allow normal development 5. Genitourinary anomalies (3) Success of treatment depends on early a. Hypospadias treatment; with early treatment prog- (1) Definition—in males, urethral open- nosis is good ing is located on ventral aspect of 7. Chromosomal abnormalities penis a. Down syndrome (2) Circumcision contraindicated— (1) Results from extra chromosome at foreskin tissue is often used in surgical pair 21 or 22 or translocation of pairs repair 15 and 21 (3) Rare in females, with urethral opening (2) Signs include close-set slanting eyes, located in the vagina narrow palpebral fissures, flattened b. Epispadias nose, large protuberant tongue, short (1) Definition—congenital absence of an- thick fingers with incurving of fifth terior urethral wall digit, simian palmar crease, nuchal (2) Often associated with other genitouri- thickening nary anomalies (3) Involves varying degrees of mental (3) Repaired surgically impairment c. Ambiguous genitalia (4) Associated with multiple congenital (1) Definition—anomalies of the external anomalies, including cardiac and GI genitalia precluding identification of tract defects the newborn’s sex b. Trisomies 13 and 18 (2) May be associated with anomalies of (1) Clinically similar to but more severe the internal genitalia than Down syndrome (3) Chromosome studies can determine (2) High mortality rates; poor life genotypic sex expectancy (4) Gender identity problems are fre- 8. Inborn errors of metabolism quent; reconstructive surgery is a. Phenylketonuria controversial (1) Definition—deficiency of phenylala- d. Exstrophy of the bladder nine hydroxylase, resulting in inability (1) Definition—exposure of bladder out- to metabolize phenylalanine side the abdominal wall (2) Results in toxic accumulation of ab- (2) Repaired surgically; often complicated normal metabolites of phenylalanine, by associated genitourinary anomalies eventually leading to CNS damage e. Patent urachus (3) Treatment—dietary restriction of (1) Definition—persistence of fetal open- foods high in phenylalanine ing between bladder and umbilical (4) Should be identified and treated be- cord fore 3 weeks of age (2) Repaired surgically Questions 155

b. Galactosemia a. The infant of a mother with diabetes (1) Definition—inability to convert galac- mellitus tose to glucose b. The infant of a mother with gestational (2) Results in toxic accumulation of galac- diabetes tose in the bloodstream c. An infant who had intrapartum fetal moni- (3) Treatment—dietary restriction of toring findings suggestive of fetal distress foods containing galactose d. The infant of an opioid-abusing mother 2. Which of the following best describes the • Sudden infant death syndrome (SIDS) appearance and behavior of an overstimulated 1. Definition—sudden unexplained death of in- infant? fant between birth and 1 year of age 2. Prevalence—2 out of 1000 infants a. Tremors, tachycardia, nonnutritive sucking, a. Most prevalent between 2 and 4 months of nasal flaring, and grunting age b. Color changes, irregular respiration, irrita- b. Rarely occurs before 3 weeks or after 9 bility or lethargy, and vomiting months c. Lethargy, flaccid tone, pallor, and inability to 3. Unknown cause maintain alert active state a. “Apnea hypothesis”—theory that sleep- d. Habituation to noxious stimuli and attempts associated apnea is the primary mecha- to self-console nism of SIDS 3. The midwife performs a physical examination b. Apnea hypothesis has led to increased use on a newborn 2 hours after birth. Which of the of home cardiorespiratory monitors following findings indicate a need for pediatric c. No evidence that home cardiorespiratory consultation? monitoring saves lives d. Subsequent research has not shown a a. Respiratory rate of 50 breaths per minute strong association between apnea and b. Intermittent episodes of apnea, lasting less SIDS than 10 seconds each 4. Risk factors c. Yellow blanching of skin when pressure is a. Gender—SIDS occurs more often in male applied to the infant’s nose than female infants d. Preauricular skin tag b. Premature birth 4. Ms. G. has just given birth, and the midwife’s c. IUGR initial impression is that resuscitation may be d. Low socioeconomic status necessary. According to American Academy of e. Young maternal age Pediatrics (AAP) and American Heart Association f. Short interpregnancy interval (AHA) guidelines, the midwife’s initial steps are, g. Maternal smoking or use of cocaine or in sequential order: opiates h. More common in cold weather months a. Place the infant under a radiant heater, dry i. More common after midnight and before the infant and remove wet linen, suction the 8:00 a.m. mouth and nose, and provide tactile stimu- j. Higher incidence in African-American or lation while assessing for the presence or Native-American infants absence of spontaneous respirations 5. Recommendations b. Place the infant under a radiant heater, a. “Back to sleep”—infants should be posi- suction the mouth and nose, and evaluate tioned in supine or side-lying position to heart rate by palpating the base of the sleep umbilical cord or femoral pulse b. Avoidance or reduction of modifiable risk c. Place the infant under a radiant heater, factors evaluate heart rate by palpating the base of c. Infants should sleep on a firm surface the umbilical cord or femoral pulse, dry the d. Avoid loose bedclothing infant and remove wet linen, suction the mouth and nose, and continue to provide Â Questions tactile stimulation d. Place the infant under a radiant heater, Select the best answer. suction the mouth and nose, evaluate for the presence or absence of spontaneous respira- 1. Which of the following infants is least at risk for tions, and dry the infant and remove wet neonatal hypoglycemia? linen 156 Chapter 5 Midwifery Care of the Newborn

5. Following the steps listed in question 4, the c. “My baby is 5 days old, but according to the midwife notes that spontaneous respiration and scale on the side of the bottle, she’s only tone are normal and the heart rate is 120 beats taking about 20 or 30 mL of formula at each per minute. Continuing to follow AAP/AHA feeding. I’m worried: shouldn’t she be eating guidelines, the midwife then: more than that by now?” d. “I’m letting my baby feed for 10 or 15 a. Initiates positive pressure ventilation with minutes on each breast, at every feeding.” 100% oxygen b. Returns the infant to the mother to facilitate 9. Which of the following statements about pro- bonding and initiate breastfeeding phylaxis for newborn eye infections is untrue? c. Evaluates the infant’s color and provides a. Due to the rapid onset of ophthalmia neo- oxygen if acrocyanosis or general cyanosis natorum, administration of silver nitrate or are present erythromycin should take priority over family d. Evaluates the infant’s color and provides bonding and initiation of breastfeeding. oxygen only if general cyanosis is present b. Erythromycin is preferred over silver nitrate, 6. With respect to question 5, how would the because it provides coverage against the two midwife proceed differently if meconium most common pathogens. staining of the amniotic fluid had been noted on c. Chlamydial conjunctivitis is the most rupture of membranes? common cause of blindness worldwide. d. The two major pathogens for newborn eye a. Suction the trachea after drying the infant infections are Nessieria gonorrhoeae and and removing wet linen Chlamydia trachomatis. b. Suction the trachea on the perineum before delivery of the thorax 10. Ms. H., who has a 1-month-old infant, contacts c. Suction the mouth, nose, and pharynx only— the midwife on call. Ms. H. sounds distraught, endotracheal suctioning is not indicated and tells the midwife that her baby “just cries d. Suction the trachea after drying the infant and cries, all the time, and cries so hard that he and providing tactile stimulation gets red in the face. He’s starting to drive me crazy!” The midwife asks questions about the 7. Which of the following statements about the baby’s temperature, feeding habits, and voiding newborn transitional period is not true? and stooling, all of which appear to be normal a. Rapid changes in the infant’s color during despite the baby’s behavior. The midwife cor- the period from 2 to 6 hours after birth rectly tells Ms. H. that: are an ominous sign and require further a. She should take the baby to the emergency evaluation. room immediately. b. The three stages, in order, are: (1) the first b. The baby’s behavior is normal and getting period of reactivity, (2) the period of unre- used to the demands of an infant is a normal sponsive sleep, and (3) the second period of part of adjusting to motherhood. reactivity c. Some babies are prone to this behavior, and c. Respiratory rales are normally present during one of the biggest problems is the effect on the first 20 minutes of life the baby’s parents—when it gets to be too d. A period of unresponsive sleep typically much, position the baby safely in his crib and begins within 30 minutes after birth and con- go outside for a “sanity break.” tinues until about 2 hours after birth d. The baby’s problem results from lack of stim- 8. Ms. F., a primipara, is discussing infant feeding ulation—put on some upbeat music, turn on with her midwife. Which statement would indi- all the lights, make sure he can move freely, cate to the midwife that further teaching is and engage him in active play. necessary to correct a misunderstanding? 11. At her 6-month well child checkup, Ms. J.’s baby a. “As long as my baby is suckling well and weighs 12 lb, compared to a birthweight of 6 lb. wetting diapers, I don’t have to worry about Ms. J. says that she seems to breastfeed well, but whether he’s getting enough milk.” frequently spits up afterward. The midwife: b. “Because I’m bottle feeding, I’m going to a. Obtains a consultation with the pediatrician stick to a regular 2-hour feeding schedule.” b. Recommends supplementation of formula in addition to continuing breastfeeding Questions 157

c. Orders metabolic screening, including a. ABO incompatibility is most common when screening for phenylketonuria the maternal blood type is A and the fetus’ d. Reassures Ms. J. that the baby’s weight gain blood type is B. is normal and reinforces her breastfeeding b. Rh incompatibility may result in neonatal technique jaundice, but rarely causes severe hemolysis or anemia. 12. Which of the following is not characteristic of c. A positive result on the direct Coombs’ test normal newborn behavior states? indicates the presence of fetal blood cells in a. Abrupt, unpredictable changes between Bra- maternal circulation. zelton’s sleep-wake states d. Hemolytic disease in the infant can be caused b. Difficulty becoming and remaining alert by maternal antibodies, enzymatic disorders, c. Irritability and rapid progression from alert- and some infections. ness to crying 17. The midwife suspects maternal opiate abuse due d. Overstimulation, requiring “time out” with to which of the following clusters of newborn limitation of stimuli signs and conditions? 13. The midwife wishes to estimate a newborn’s a. Prematurity, low birth weight, genitourinary gestational age. Which standard instrument is abnormalities, congenital heart disease, irri- appropriate? tability, and frantic ineffective sucking a. Denver II b. Irritability, tremors, high-pitched cry, b. Ballard hyperstimulability, tachypnea, tachycardia, c. Erikson disorganized feeding, hyperthermia, and d. Erb-Duchene vasomotor instability c. Microcephaly, facial abnormalities, cardiac 14. Which of the following statements about the defects, and malformation of joints major psychological tasks of early infancy is d. Lethargy, diminished reflexes, and hypotonia untrue? 18. Which of the following assessment findings are a. Secure attachment is facilitated by caregivers most consistent with prematurity? who demonstrate predictable responses and emotional availability. a. Translucent skin, sparse lanugo, flat areolae, b. The development of basic trust is essential prominent clitoris and labia minora, and for formation of relationships later in life. highly flexible, nonrecoiling ear tissue c. Research has not been able to demonstrate b. Scant rugation of scrotum, undescended any long-term effects of insecure attachment testes, and wrinkled, cracked, peeling skin in early infancy. c. Extended posture, flaccid tone, little resis- d. A major issue is the infant’s ability to elicit tance to flexion of extremities, and increased caregiving responses from his or her mother. recoil of ear tissue d. Abundant lanugo, flexed posture, skin 15. The midwife’s discussion about circumcision with creases covering entire plantar surface, and the infant’s parents should acknowledge that: relatively low-set position of ears a. The medical benefits of circumcision are 19. Prominent vasculature of the anterior lens well-established and outweigh the risks, capsule is most suggestive of which condition? which are rare. b. The risks of circumcision, while rare, are a. Herpes virus exposure in the intrapartum potentially serious and outweigh any pos- period sible medical benefit. b. Relatively immature gestational age c. Research has proven that circumcision has a c. Gonococcal or chlamydial conjunctivitis negative impact on long-term psychological d. Elevated total serum bilirubin concentration and sexual functioning. 20. Compared to fetal circulation, which of the fol- d. Decisions about circumcision are largely lowing is not characteristic of circulation after based on personal, cultural, and religious birth? considerations. 16. Which of the following statements about hemolytic disease is true? 158 Chapter 5 Midwifery Care of the Newborn

a. Increased pressure in the left atrium facili- 25. Within the first day of life, the midwife notices tating closure of the foramen ovale that Ms. O.’s baby drools copiously, feeds poorly b. Relatively low pulmonary vascular resistance with excessive reflux, and turns bluish-grey while resulting in increased circulation to the lungs feeding. Which condition does the midwife c. Decreased systemic vascular resistance due to suspect? loss of high-resistance placental circuit a. Tracheoesophageal malformation d. Increased oxygenation of circulating blood b. Pyloric stenosis causing constriction of the ductus arteriosus c. Gastroschisis 21. Mr. N. is concerned about Ms. N.’s positive tuber- d. Oomphalocele culosis screening result. While awaiting results 26. Increased oxygen consumption, hypoglycemia, from Ms. N.’s chest radiograph and sputum hypoxia, acidosis, and respiratory distress can culture, the midwife tells Mr. N. that: be caused in the immediate newborn period a. Even if the chest radiograph is negative, Ms. by: N.’s exposure will necessitate a period of a. Congenital bacterial infections isolation from the newborn which may inter- b. Maternal opioid abuse fere with the initiation of breastfeeding. c. Patent ductus arteriosus b. Congenital tuberculosis is unlikely to be a d. Cold stress in the birthing room problem for the newborn, since Ms. N. shows no signs of active disease. 27. Relatively mature capabilities of the newborn’s c. If the newborn acquires tuberculosis in gastrointestinal system include: utero, the most serious risk is for respiratory a. Suckling, swallowing, and gag reflex problems in the neonatal period. b. Ability to digest fats and proteins d. Subclinical maternal tuberculosis infection c. Absorption of complex sugars is associated with a number of congenital d. Cardiac sphincter tone malformations. 28. At 1 minute of age, Baby P exhibits a strong cry, 22. Which of the following newborn assessment some flexion of the arms and legs, heart rate of findings is/are least likely to be related to 136 beats per minute, and acrocyanosis. Baby P’s maternal gestational diabetes? 1-minute Apgar score is: a. High-pitched cry, plethora, tachypnea, and a. 6 inconsolability b. 7 b. Weak cry, jitteriness, cyanosis, apnea, poor c. 8 feeding, and lethargy d. 9 c. Serum glucose level below 40 mg/dL d. Absent Moro reflex on right side, and pal- 29. At 5 minutes of age, Baby Q exhibits slow irreg- pable crepitus between the right shoulder ular respirations, some flexion of extremities, and neck heart rate of 96 beats per minute, grimace in response to suction, and generalized cyanosis. 23. A defect in the vertebral column resulting in Baby Q’s 5-minute Apgar score is: extrusion of meninges and cerebrospinal fluid is best described as: a. 4 b. 5 a. Spina bifida occulta c. 6 b. Hydrocephaly d. 7 c. Myelomeningocele d. Meningocele 30. Which of the following statements about Apgar scores is true? 24. Which of the following conditions is most likely to result in loss of sensory and motor function a. The infant’s Apgar score indicates whether below the level of the defect? or not resuscitation is needed and which steps of resuscitation procedure should be a. Spina bifida occulta initiated. b. Hydrocephaly b. The 1-minute Apgar score is more predictive c. Myelomeningocele of cord pH and long-term outcome than is d. Meningocele the 5-minute Apgar score. Questions 159

c. The 1-minute Apgar score is more predictive c. Primary diaper dermatitis, characterized by of cord pH, while the 5-minute Apgar score circumscribed areas of bright red erythema is more predictive of long-term outcome. and smaller outlying lesions, can be treated d. The Apgar score is only useful as a system- with thorough cleaning, baby powder, and atic way to assess the newborn’s immediate air exposure. adaptation to extrauterine life. d. Tub baths should be avoided for the first 2 weeks of life or so until the cord stump has 31. In the initial examination of a male infant, the fallen off. midwife notes drainage of urine from the stump of the umbilical cord. The newborn’s condition is 35. Which of the following newborns is not a candi- most likely: date for early discharge? a. Patent urachus a. Metabolic screening tests have not been b. Epispadias completed; the baby has an appointment c. Hypospadias with the pediatric provider in 2 days. d. Exstrophy of the bladder b. Congenital hip dislocation is suspected; the baby has an orthopedic appointment in 2 32. Which of the following is not a true statement weeks for evaluation and treatment. about the newborn’s first breaths? c. The infant’s birth weight was 2625 g; gesta- a. The first inhalation requires less ventilatory tional age assessment indicates term infant. pressure than later breaths. d. The infant requires phototherapy; a home b. The first breaths trigger the conversion from health agency referral has been made. fetal to extrauterine circulation. 36. The midwife is examining Baby S prior to dis- c. Initial breathing serves to clear the lungs of charge. She notes that the head circumference fluid. is 34 cm, while the chest circumference is 31 cm. d. The first breaths establish lung volume and The midwife should: expand the alveoli. a. Assess for further signs of hydrocephalus, 33. Which of the following is a true statement about including separation of cranial sutures, thermoregulation in the transitional period? bulging fontanelles, high-pitched cry, and a. Shivering and muscular activity are the downward deviation of the eyes newborn’s most effective means of b. Repeat the measurements—these findings thermogenesis. are extremely unlikely b. Convection, conduction, radiation, and c. Suspect diaphragmatic hernia—measure- evaporation are important thermoregulatory ment of abdominal circumference and mechanisms in the newborn period. location of heart, lung, and bowel sounds c. Metabolism of BAT is limited as a means may give some indication of thermoregulation, because BAT stores d. Proceed to the next component of the cannot be renewed once they are used. examination without further investigation of d. Alkalosis is a potentially serious consequence these findings of ineffective thermoregulation in the 37. Evaluation of the newborn begins: newborn. a. Before the infant is born 34. Patient education about newborn skin care b. When the presenting part is crowning includes: c. At the moment of birth a. “Cradle cap,” a crusty yellowish-white accu- d. After initial stabilization and resuscitation, if mulation on the anterior scalp, is caused by necessary Candida albicans and must be treated with a 38. Which of the following statements is true of topical antifungal agent. small for gestational age infants? b. Dry or peeling skin can be treated with baby oil, but if the condition does not resolve a. Symmetric growth restriction results from quickly the healthcare provider should be chronic conditions, and is typically associated notified. with “catch-up growth” and good long-term outcome. b. An infant is considered small for gestational age if he/she weighs less than 1500 grams at birth. 160 Chapter 5 Midwifery Care of the Newborn

c. An infant with head circumference above c. Most are characterized by enzyme defi- the 45th percentile and birth weight ciency, resulting in toxic accumulation of below the 10th percentile for gestational metabolites age would be described as asymmetrically d. Breastfeeding is strongly recommended for growth restricted. infants with galactosemia. d. Asymmetric growth restriction is associated 45. Which of the following is not an associated with acute insults in late pregnancy, and is combination of intrapartum factor and neonatal associated with poor long-term outcome. finding? 39. Baby U has the most abundant lanugo the a. Forceps delivery—cephalohematoma midwife has ever seen. Baby U’s gestational age b. Vertex presentation—asymmetry of gluteal is probably: folds a. 24 to 26 weeks c. Shoulder dystocia—asymmetric Moro reflex b. 26 to 28 weeks d. Breech presentation—positive Ortolani sign c. 32 to 34 weeks 46. Visible gastric peristalsis on observation of the d. 36 to 38 weeks abdomen is most suggestive of: 40. Which of the following is not associated with a. Pyloric stenosis microcephaly? b. Esophageal fistula a. Prenatally acquired toxoplasmosis c. Colic b. Prenatally acquired hepatitis B d. Normal finding c. Fetal alcohol syndrome 47. Normal newborn respiratory findings include: d. Prenatally acquired HIV a. Nasal flaring, expiratory grunting, and 41. Ms. V. asks her midwife about sudden infant retractions death syndrome (SIDS) during her 6-week post- b. Diaphragmatic and abdominal breathing partum visit. In discussing SIDS with Ms. V., the c. Respiratory rate 40 to 80 breaths per minute midwife states that: d. Ventilation primarily through the mouth a. SIDS almost never occurs after 6 weeks of 48. Nonnutritive sucking age, so her baby is “in the clear.” b. SIDS is extremely rare, affecting less than 2 in a. Is not known to occur before birth 100,000 infants. b. Should be discouraged to prevent dental and c. The exact cause of SIDS is unknown. facial malformations d. Infants should be put to sleep in a prone or c. Is an example of behavioral self-regulation side-lying position. d. Can be promoted by placing a pacifier on a string around the baby’s neck 42. The normal newborn’s sensory capacities are most limited in: Â Answers a. Color perception b. Hearing â 1. d 14. c c. Taste sensation â 2. b 15. d d. Near vision focus â 3. c 16. d 43. The organized infant is able to: â 4. a 17. b a. Form significant relationships with others â 5. d 18. a throughout life â 6. c 19. b b. Hear high-pitched sounds â 7. a 20. c c. Self-console and return to a stable behav- â 8. b 21. b ioral state â 9. a 22. a d. Sleep for 20–25% of daytime hours 10. c 23. d 44. Which of the following is a true statement about 11. d 24. c newborn metabolic disorders? 12. a 25. a 13. b 26. d a. Federal law mandates testing for phenylketonuria, galactosemia, and cystic fibrosis b. For early-discharge neonates, screening at 8 hours of life is acceptably reliable Bibliography 161

27. a 38. c Kenner, C. (2004). Neonatal nursing (1st ed.). Philadel- 28. c 39. b phia, PA: W. B. Saunders. Lowdermilk, D., & Perry, S. (2007). Maternity and wom- 29. a 40. b en’s health (9th ed.). St. Louis: Mosby, Inc. 30. d 41. c Papalia, D. E., Olds, S. W., & Feldman, R. (2009). Human 31. a 42. a development (11th ed.). New York: McGraw-Hill. 32. a 43. c Polin, R. A., Fox, W. W., & Abman, S. (2004). Fetal and 33. c 44. c neonatal physiology (3rd ed.). Philadelphia, PA: W. B. 34. d 45. b Saunders. 35. b 46. a Riordan, J., & Auerbach, K. G. (2010). Breastfeeding and 36. d 47. b human lactation (4th ed.). Sudbury, MA: Jones and Bartlett. 37. a 48. c Rudolph, C. D., & Abraham, M. R. (Eds.). (2010). Ru- dolph’s pediatrics (22nd ed.). Chicago: McGraw-Hill. Â Bibliography Seidel, H. M., Rosenstein, B. J., & Pathak, A. (2006). Pri- mary care of the newborn (4th ed.). St. Louis: Mosby, American Academy of Pediatrics. (2006). Textbook of Inc. neonatal resuscitation (5th ed.). Elk Grove, IL: Ameri- Tappero, E. P., & Honeyfield, M. E. (2009). Physical as- can Academy of Pediatrics. sessment of the newborn (4th ed.). Petaluma, CA: Centers for Disease Control and Prevention (CDC). NICU Ink. (2010). Recommended immunization schedule for Varney, H., Kriebs, J. M., & Gegor, C. L. (2004). Varney’s persons age 0 through 6 years—United States. Atlanta, midwifery (4th ed.). Sudbury, MA: Jones and Bartlett. GA: Author. Retrieved on May 5, 2010 from www.cdc. Volpe, J. J. (2008). Neurology of the newborn (5th ed.). gov/vaccines/recs/schedules. Philadelphia, PA: W. B. Saunders.

6 Intrapartum and Postpartum

Susan P. Shannon

¶ INITIALASSESSMENT (a) Pregnancy-induced hypertension (b) Preterm delivery UÊ -V`i}À>« VÃ (c) Gestational diabetes 1. Age—opposite ends of the age spectrum create (d) Dysfunctional labor leading to risks Cesarean section a. Adolescents (e) Relationship to underlying dis- (1) Prone to late entry to care and poor ease processes compliance with prenatal care (f) Placenta previa and abruption schedule 2. Race/Ethnicity (2) At risk for low birth weight and a. Increased rate of low birth weight babies prematurity born to African-American and Hispanic (3) Increased risk of women (a) Pregnancy-induced hypertension b. Certain genetic disorders are increased (b) Premature labor within specific ethnic groups (c) Preterm birth 3. Socioeconomic status (d) Intrauterine growth restriction a. Lower socioeconomic status directly pro- (IUGR) portional to poor obstetrical outcome in- (e) Infant mortality cluding premature labor and delivery (4) Risk probably multifactorial with as- b. Can be related to limited access to prena- sociated socioeconomic factors tal care and necessary resources such as (a) Parity appropriate food sources (b) Race (c) Marital status UÊ À>Û`ÌÞÊ>`Ê«>ÀÌÞ (d) Educational level 1. Length of labor b. Advanced maternal age for pregnancy is a. Nullipara average longer labors older than age 35 b. Multipara average shorter labors (1) Higher incidence of infertility and first c. Grand multiparous women (parity > 5) trimester spontaneous abortion and can have prolonged dysfunctional labors ectopic pregnancy 2. Obstetrical complications (2) Proportional increase in rates of ge- a. Increased parity associated with increased netic abnormalities with advancing rates of age (1) Abruptio placenta (3) Increased rates of complications (2) Placenta previa including: (3) Multifetal pregnancy

163 164 Chapter 6 Intrapartum and Postpartum

(4) Postpartum hemorrhage • Obstetrical history b. Grand multiparity can contribute to ab- 1. Gravidity—total number of pregnancies normal presentation including transverse 2. Parity—outcome of previous pregnancies lie a. Expressed as a four-digit number (TPAL) b. First digit is full-term infant (T); second • Estimated gestational age—determination of esti- digit is preterm infant (P); third digit is mated date of confinement (EDC) abortions/terminations (A); fourth digit is 1. Menstrual dating (using Naegele’s rule)—add living children (L) 7 days to the first day of the last menstrual pe- 3. Description of previous pregnancies riod and subtract 3 months a. Duration of gestation 2. Ultrasound dating—most accurate if per- b. Birth weight formed in the first trimester c. Duration of labor 3. Anatomical dating by fundal height d. Type of delivery measurement e. Analgesia/anesthesia f. Complications of the prenatal, intrapar- • Review of the antepartum course—preferably us- tum, or postpartum period ing prenatal chart g. Place of delivery 1. History of prenatal visits h. Provider a. Timing of first visit b. Compliance with visit schedule • Past medical history c. Unscheduled visits/consults 1. Allergies 2. Weight gain 2. Medical conditions a. Prepregnancy weight 3. Previous surgeries b. Appropriateness of interval weight gain 4. Medication and herb use c. Total weight gain 3. Blood pressure • Review of systems a. Initial blood pressure 1. Genitourinary b. Changes in blood pressure values 2. Respiratory throughout pregnancy 3. Cardiovascular 4. Fundal height growth 4. Gastrointestinal 5. Ultrasound results 5. Neurologic 6. Current medications 6. Musculoskeletal 7. Obstetrical complications/unscheduled visits • Labor status • Laboratory data 1. Onset of contractions 1. Blood type and Rh factor 2. Description of contractions 2. Hemoglobin/hematocrit a. Frequency 3. Hepatitis B antigen status b. Duration 4. Rubella status c. Intensity 5. Pap test result 3. Status of membranes 6. STD screening results a. Time of rupture 7. Glucose screening b. Amount 8. Group B streptococcus culture c. Color 9. Genetic testing results 4. Frequency of fetal movements a. Chorionic villus sampling 5. Presence or absence of bloody show b. Amniocentesis 6. Other subjective symptoms c. Triple screen a. Nausea and vomiting b. Rectal pressure • Family history 1. Obstetrical complications Â Physical Examination 2. Genetic diseases including chromosomal abnormalities and ethnicity-based disorders • Vital signs 3. Congenital defects or syndromes 4. Medical disorders • Abdominal examination a. Hypertension (HTN) 1. Leopold’s maneuver for fetal presentation and b. Diabetes position during labor c. Cardiac disease Physical Examination 165

a. Determination of attitude is more difficult (b) Symphysis pubis joins the two secondary to fetal descent innominate (pubic) bones b. Location of fetal back provides best deter- anteriorly mination of fetal position without pelvic (c) True pelvis defines the birth canal examination i. Inlet is at the level of the 2. Palpation of contraction intensity sacral promontory, linea ter- 3. Presence of fetal movement minalis, and the upper mar- 4. Location of fetal heart tones gins of the pubic bones ii. Midplane of the pelvis is the • Pelvic examination inferior margins of the ischial 1. External perineal inspection tuberosities and the tip of the a. Presence of bloody show coccyx b. Presence of amniotic fluid iii. Outlet is the anterior surfaces c. Presence of lesions of the sacrum and coccyx 2. Internal examination (d) Classification of pelvic types a. Sterile speculum examination—before i. Gynecoid digital examination if ruptured mem- a) Round shaped pelvis branes are suspected, frank bleeding is b) Transverse diameter present, or inspection for herpetic lesions only slightly longer than is necessary anteroposterior b. Digital examination c) Incidence—50% of white (1) Dilation women (2) Effacement d) Excellent prognosis for (3) Station—relationship of the fetal pre- vaginal birth senting part to the ischial spines (in ii. Android centimeters) a) Heart shaped or triangu- (a) 0 station—the presenting part is lar shaped pelvis at the level of the spines b) Posterior pelvis wider (b) –3, –2, –1 station—presenting than anterior part above the level of the ischial c) Poor prognosis for vagi- spines nal birth requiring opera- (c) +1, +2, +3 station—presenting tive delivery or C-section part below the level of the ischial iii. Anthropoid spines a) Oval shaped pelvis (4) Presenting part—the anatomical part b) Anteroposterior diameter of the fetus that first descends into the is longer than transverse pelvis diameter (5) Position—relationship between the c) Incidence—50% of denominator of the presenting part nonwhite and the maternal pelvis d) Good prognosis of (a) Cephalic presentation—the de- vaginal birth—higher nominator is the occiput incidence of occiput pos- (b) Breech presentation—the denom- terior position inator is the sacrum iv. Platypelloid (c) Shoulder presentation—the de- a) Flattened gynecoid shape nominator is the scapula pelvis (d) Face presentation—the denomi- b) Wide transverse diameter nator is the mentum with very short antero- (6) Status of membranes posterior diameter (7) Clinical pelvimetry—determination of c) Incidence—3% adequacy of bony pelvis d) Very poor prognosis for (a) The pelvis is composed of four vaginal birth bones i. Two innominate • Fetal heart rate assessment ii. Sacrum 1. Continuous—by external electronic fetal iii. Coccyx monitor a. Determination of the fetal heart rate 166 Chapter 6 Intrapartum and Postpartum

b. Assessment of long-term variability • Cervical/Vaginal/Perineal cultures performed dur- c. Determine presence or absence of pe- ing sterile speculum examination, if indicated riodic changes including decelerations, 1. Cervical culture if suspect active infection or tachycardia, or bradycardia has prolonged rupture of membranes (PROM) 2. Continuous—by internal monitoring via fetal 2. Culture of any suspicious lesions scalp electrode 3. Vaginal and rectal cultures for group B strepto- a. Measures the actual R-to-R interval of coccus (GBS) if rupture of membranes before the fetal QRS complex; more accurate 37 weeks and not yet laboring surveillance b. Can determine short-term variability Â Management and Teaching 3. Intermittent by Doppler a. Auscultation of fetal heart rate at pre- • Based upon birth facility’s policies, client desire, scribed intervals based upon stage of labor and risk status for discussion, consultation and to assess fetal tolerance of labor management options b. Unable to determine variability or isolated decelerations • Admission vs outpatient management 1. Generally admit during active labor; client • Head-to-toe examination may desire outpatient management 1. General affect and coping abilities 2. Factors to consider in decision making 2. Head, eyes, ears, nose, and throat a. Stage of labor a. Absence of facial edema b. Nullipara vs multipara b. Absence of URI signs c. Functional vs prodromal labor 3. Heart and lungs d. Labor support at home a. Heart sounds without murmurs, rubs, or e. Need for increased fetal surveillance gallops—may have split S1, I/VI systolic murmur, audible S3 • Intravenous access b. Lungs clear to auscultation 1. If intravenous access is necessary via saline 4. Abdomen lock or IV catheter, most-common IV fluids a. Fundal height and appropriateness to ges- are: tational age a. 5% Dextrose solution b. Leopold’s maneuver if not performed b. 5% Dextrose with Lactated Ringer’s previously c. Lactated Ringer’s c. Presence of scars or lesions 2. Factors to consider in decision making d. Intensity of contractions by palpation a. Hydration status, including presence of e. Location of fetal heart tones ketonuria 5. Pelvic examination—described in detail in this b. Need for oxytocin induction or chapter augmentation 6. Extremities c. Need for antibiotics a. Presence or absence of edema d. Predisposing factors for postpartum hem- b. Presence or absence of varicosities orrhage such as an overdistended uterus c. Reflexes e. Abnormal placentation f. Grand multiparity Â Diagnostic Studies g. Need for pain medication or regional anesthesia • Type of studies—dependent upon policies of birthing facility • Limitations of activity level 1. Complete blood count 1. Clients can be encouraged to ambulate to help 2. Blood type and Rh—may need to type and labor progress and coping abilities screen or cross-match depending on maternal 2. Factors to consider in decision making risk status a. Unstable lie or malpresentation 3. Repeat testing for HIV, syphilis, or hepatitis if b. Need for increased fetal surveillance and indicated by history or examination findings monitoring c. Membrane status and station of the pre- • Urine testing senting part 1. Protein d. Pregnancy induced hypertension 2. Glucose e. Maternal exhaustion level 3. Ketones Management and Teaching 167

• Nutrition and fluid status a. Paracervical 1. Energy levels can be positively influenced by b. Pudendal oral intake c. Local infiltration 2. Factors to consider in decision making a. Gastrointestinal motility/absorption • Fetal well-being monitoring—method used depen- b. Potential need for anesthesia during labor dent upon risk status of mother, policy of the birth c. Birthing facility policy facility, and provider preferences in combination 3. Can consider gastrointestinal protective with mother’s desires agents such as magnesium/aluminum hydrox- 1. Intermittent auscultation ide, calcium carbonate/magnesium hydroxide, a. Facilitates increased mobility and sodium citrate/citric acid combinations b. Increased patient comfort c. Equivalent to continuous fetal monitoring • Monitoring of vital signs when performed at appropriate intervals 1. Dependent upon stage of labor and risk status d. Requires one-to-one labor attendance 2. Patients with ruptured membranes re- e. Associated with decreased rates of quire more frequent vital signs, especially intervention temperature 2. Continuous fetal monitoring a. May be indicated for antepartum or intra- • Pain management during labor and delivery partum risk factors 1. Nonpharmacologic methods b. Reactive fetal monitor tracing is predictive a. Have no effect on fetus or progress of la- of a well-oxygenated fetus bor, can allow the woman to feel more in c. Interpretation of fetal well-being can be control of the birth process equivocal in the presence of nonreassur- b. Can be used in the latent phase of labor ing fetal heart rate tracing without detrimental effect—especially helpful in latent labor • Support people and their roles (1) Ambulation and movement 1. Labor support can improve a woman’s percep- (2) Hydrotherapy tion of her labor (3) Breathing and relaxation/ 2. One-to-one labor support can assist the hypnotherapy woman to cope better with labor (4) Music 3. Dedicated labor support has been found to (5) Position changes decrease use of obstetrical intervention 2. Analgesia a. Used to ameliorate the pain sensation; • Management of membranes may change and alter consciousness; 1. Intact membranes provide a barrier to bacte- some medications have amnesiac effect rial introduction to the uterus b. Can be used in latent and active phase 2. Intact membranes can facilitate rotation of the c. Avoid within 1 hour of birth due to the po- head during pelvic descent tential respiratory depressant effect on the 3. Early rupture of membranes with unengaged fetus vertex can increase risk of cord prolapse (1) Hypnotic 4. The prostaglandin content in the amniotic (2) Sedatives fluid can assist in the augmentation of labor if (3) Narcotics dysfunctional or arrested 3. Anesthesia a. Provides complete neurologic block • Physician role b. Can interfere with muscular action 1. Clarify with the client the CNM role in relation c. Possible effect on the labor progress; may to the consulting physician cause an increase in need for obstetrical 2. Indications for physician involvement should intervention due to interference with uter- be reviewed ine contractility d. Can have systemic effects, including fever • Birth preferences and hypotension 1. Birth plan should be reviewed with client upon e. Can cause spinal headache admission and discussed in relation to status (1) Spinal/intrathecal at that time (2) Epidural 2. Discussion with client regarding inability to 4. Local blocks—provide pain blockade at site of control labor process pain for brief periods of time 168 Chapter 6 Intrapartum and Postpartum

Â Mechanisms of Labor ii. Multipara should be 14 hours or less • The 4 Ps of labor (2) Active labor—from 4 to 10 cm, begins 1. Power of contractile efforts with the acceleration phase and ends a. Adequacy of strength with the deceleration phase just prior b. Need for augmentation of labor to complete dilatation 2. Passenger (a) Contraction pattern a. Lie i. Become more frequent, regu- b. Presentation lar, and intense c. Position ii. In active labor, every 2 to 3 d. Size minutes lasting at least 60 e. Synclitism vs asynclitism seconds (1) The relationship of the sagittal suture iii. Moderate to strong by line to the maternal sacrum and sym- palpation physis pubis (b) Length (2) Synclitism denotes the sagittal suture i. Nullipara at least 1.2 cm/ is midway between these two bones; hour; average is 3 cm/hour biparietal diameter is parallel to the during maximum slope planes of the pelvis ii. Multipara at least 1.5 cm/ (3) Asynclitism denotes that the sagittal hour; average is 5.7 cm/hour suture is oriented towards the pubis or (c) Strength of contractions the sacrum i. Externally measured by (a) Posterior asynclitism—the sagittal palpation suture is closer to the symphysis ii. Internally pubis a) By intrauterine pressure (b) Anterior asynclitism—the sagittal catheter (IUPC) suture is closer to the sacrum b) Adequacy is considered (c) Can be the cause of labor dystocia 200 Montevideo (mVu) in (d) Lax abdominal musculature con- a 10-minute period tributes to asynclitism (d) Descent 3. Passage i. Nullipara at 1 cm/hr or a. Clinical pelvimetry greater, average 1.6 cm/hr b. Classification of the pelvic structure ii. Multipara at 2.1 cm/hr or 4. Psyche greater, average 5.4 cm/hr a. Woman’s view of labor/birth and her abil- b. Second stage of labor—from full dilatation ity to handle it until the birth of the baby; pushing or ex- b. Appropriateness of emotional support pulsive phase c. Education or preparation of labor 2. Abnormal labor progress—according to d. Meaning of the pregnancy Friedman e. Ability to achieve birth plan a. Abnormal latent phase f. History of sexual abuse (1) Nullipara, more than 20 hours (2) Multipara, more than14 hours • Labor assessment and progress b. Abnormal active phase 1. Stages of labor—Friedman’s concepts (1) Nullipara progress, less than a. First stage—from onset of regular contrac- 1.2 cm/hr tions through full dilatation (10 cm) (2) Multipara progress, less than (1) Latent labor—from onset of labor un- 1.5 cm/hr til 4 cm (3) Less than 200 mVu in 10 minutes by (a) Contraction pattern IUPC i. Every 10–20 minutes last- c. Descent ing 15–20 seconds to every (1) Nullipara, less than 1 cm/hr 5–7 minutes lasting 30–40 (2) Multipara, less than 2.1 cm/hr seconds 3. Evidence growing that challenges Friedman’s ii. Mild to moderate intensity parameters (b) Length i. Nullipara should be 20 hours or less Management of the First Stage of Labor 169

Â Management of the First • Pain management Stage of Labor 1. Basis of labor pain a. Physiologic • Assessment of maternal status (1) Intensity of contractions 1. Psychological status of client (2) Degree of cervical dilatation a. Perception of pain (3) Descent of fetus causing pressure on b. Coping ability and coping strategies pelvic structures c. Presence and support of people (4) Fetal size d. Client’s perception of need for admission (5) Fetal position to the birthing facility (6) Hypoxia of uterine muscle cells during 2. Physical status of the client action of contractions a. Vital signs b. Psychological (1) Temperature (1) Fear (a) Slightly elevated (< 100°F) during (2) Anxiety labor, highest in the time preced- (3) Lack of knowledge regarding labor ing and immediately following the process birth (4) Lack of support (b) Epidural anesthesia can artifi- (5) Cultural influences cially elevate temperature 2. Negative physiologic responses related to la- (2) Blood pressure bor pain (a) Systolic blood pressure increases a. Hyperventilation causing decreased 10–20 mm Hg during contractions oxygenation (b) Diastolic blood pressure increases b. Stress responses—related psychological 5–10 mm Hg during contractions effect causes increased cortisol and de- (c) Blood pressure returns to prelabor creased placental perfusion levels between contractions c. Increased cardiac output and blood (d) Pain and fear can contribute to pressure elevations in blood pressure 3. Factors influencing pain management (3) Pulse decisions (a) Due to the increased metabolic a. Patient choice or birth plan rate during labor, pulse rate is b. Stage of labor slightly elevated c. Fetal status (b) Inversely proportional to action of d. Other factors contributing to pain the contraction, increases during response increment and decreases at acme e. Possible routes of medication (4) Respiration administration (a) Slightly increased rate during f. Availability of pain medication modalities labor g. Nursing staff availability (b) Hyperventilation is common and 4. Pain management methods related to pain response and can a. Nonpharmacologic pain relief lead to alkalosis (1) Relaxation and breathing techniques (2) Hydrotherapy—tub, shower, Jacuzzi • Assessment of labor progress (3) Position changes; ambulation 1. Vaginal examinations (4) Massage a. Allows assessment of labor progress re- (5) Environmental measures, i.e., quiet lated to cervical dilatation and/or fetal surroundings, aromatherapy, music descent (6) Acupuncture b. Frequency of vaginal examinations depen- (7) Hypnosis dent upon phase of labor, provider choice, b. Pharmacologic pain relief client’s wishes, and status of membranes (1) Sedatives used for false labor or pro- 2. Partographs—graph of labor curve dromal labor, facilitate rest/relaxation a. Designed by Dr. Emmanuel Friedman to (a) Diphenhydramine 25–50 mg chart labor progress to assure adequacy (b) Zolpidem 5–10 mg b. Expectation of standard progress of labor (c) Pentobarbital 100 mg by Friedman’s formula not universally (2) Ataractics—do not affect contraction accepted pattern, have a calming effect 170 Chapter 6 Intrapartum and Postpartum

(a) Promethazine 25–50 mg IM or 25 (2) Marked bradycardia is less than 100 mg IV bpm for 10 or more minutes (b) Hydroxine 25–50 mg IM (a) Causes (3) Narcotic analgesics given in active la- i. Cord compression bor but should be avoided within ii. Rapid descent 1 hour of birth iii. Vagal stimulation (a) Meperidine 50 mg IM or 25–50 mg iv. Medications IV v. Anesthesia or medications (b) Morphine sulfate for prodromal vi. Placental insufficiency labor 10–15 mg IM or active la- vii. Fetal cardiac anomalies bors 3–5 mg IV viii. Terminal condition of the (4) Nonnarcotic analgesics—cause less fetus neonatal respiratory depression than c. Tachycardia narcotics (1) FHR of more than 160 bpm for more (a) Butorphanol 1–2 mg IV or 1–4 mg than 10 minutes IM (a) Causes (b) Nalbuphine 10–20 mg IM or 5 mg i. Maternal fever IV ii. Infection c. Anesthesia iii. Medications, especially beta (1) Spinal/intrathecal sympathomimetics (2) Epidural iv. Chronic fetal hypoxia (3) Pudendal v. Can be compensatory after temporary fetal hypoxia event • Assessment and evaluation of fetal well-being vi. Undiagnosed prematurity 1. Physiology of fetal heart rate (FHR) regulation vii. Excessive fetal movement a. Parasympathetic nervous system—re- d. Variability sponsible for the beat-to-beat variability (1) Combination of influences between of the FHR the sympathetic and parasympathetic b. Baroreceptors nervous systems (1) Increased pressures can cause vagal (a) Long-term variability (LTV)— response in the fetus fluctuations of the fetal heart rate (2) Located in the carotid arteries over the course of 1 minute c. Chemoreceptors i. Absent, less than 2 bpm from (1) Located in the aortic arch and carotid baseline sinus ii. Decreased, 2–6 bpm from (2) Sensitive to changes in the fetal pH, baseline

O2 and CO2 levels, and respond by iii. Average, 6–10 bpm from increasing fetal blood pressure and baseline heart rate iv. Increased, 15–25 bpm from d. Sympathetic nervous system—controls baseline the baseline fetal heart rate v. Marked, more than 25 bpm 2. Evaluation of the FHR in labor from baseline a. Baseline (b) Short-term variability (STV)— (1) Normal range for a fetus at term changes in fetal heart rate be- 120–160 beats per minute (bpm) tween individual beats of the fetal (2) FHR between 110–120 bpm can be heart normal at term with appropriate i. Beat-to-beat variability variability ii. Cannot be assessed by exter- (3) Judged over approximately 10–20 min- nal fetal monitoring; must utes, the mean FHR in the absence of have fetal scalp electrode periodic changes (FSE) (4) Should be documented as a 5 bpm e. Periodic changes range (1) Variable decelerations b. Bradycardia (a) Periodic or nonperiodic decrease (1) FHR at less than 120 bpm for 10 or in the FHR that differs in shape more minutes from one deceleration to another Management of the First Stage of Labor 171

(b) FHR deceleration does not reflect (b) FHR may or may not remain the shape of the contraction within the normal fetal heart (c) Can occur at any time in relation range to the contractions (c) Can occur in an isolated fashion (d) Nonconsistent shape; can look but more ominous when occurs like a U, V, or W repetitively (e) Generally with an abrupt drop be- (d) Possible causes low the FHR baseline and a rapid i. Uteroplacental insufficiency return to baseline ii. Fetal hypoxia (f) Generally caused by cord iii. Uterine hyperstimulation compression iv. Decreased placental blood (g) Implications flow i. With rapid recovery to base- v. Maternal hypotension line and good STV, generally vi. Abruptio placenta considered an uncompro- vii. Medication effect mised fetus (e) Management ii. Suspect fetal compromise i. Left lateral position with slow recovery to base- ii. IV fluid bolus

line, increasing length or iii. O2 at 10 LPM depth of deceleration, absent iv. Attempt to correct underlying STV or compensatory “over- cause shoot” of baseline, or increas- v. Consult with physician ing frequency of deceleration 3. Fetal monitoring techniques (h) Management a. All women require some method of fetal i. Position change monitoring in labor ii. IV fluid bolus b. Modality is based upon maternal/fetal risk

iii. O2 at 10 liters per minute status, birth site, and client desire (LPM) via face mask c. For low-risk women, intermittent auscul- iv. Pelvic examination, to rule tation is equivalent to continuous fetal out cord prolapse and provide monitoring to detect fetal compromise scalp stimulation d. FHR monitoring techniques v. Contact consulting physician (1) Intermittent FHR auscultation by feto- if warranted scope or Doppler vi. Consider amnioinfusion (a) Should be considered for low-risk (2) Early decelerations pregnancies (a) Uniformly shaped slowing of the (b) Frequency of auscultation—de- FHR that mirrors the contractions pendent also on facility protocol (b) Gradual descent to the nadir with i. Auscultate for 60 seconds gradual return after a contraction every 30 (c) FHR usually remains within the minutes in the first stage of normal range and deceleration labor, if low risk; every 15 usually less than 90 seconds minutes if high risk (d) Deceleration begins, peaks, and ii. Every 15 minutes during the ends with the contraction second stage of labor if low (e) Generally caused by head com- risk, every 5 minutes if high pression, vagal stimulation risk (f) Generally not considered an omi- (2) Continuous fetal monitoring nous pattern (a) Recommended for high-risk (g) Management pregnancies or when intermittent i. Position change monitoring is not indicated ii. Surveillance (b) Frequency of FHR tracing review (3) Late decelerations i. Every 15 minutes in the first (a) Uniformly shaped slowing of the stage FHR which begins with the peak ii. Every 5 minutes in the second of the contraction and does not stage return to baseline until after the (c) Modalities for continuous fetal completion of the contraction monitoring 172 Chapter 6 Intrapartum and Postpartum

i. External FHR—ultrasound 4. External uterine monitoring detection and tracing of the a. Tocodynameter—senses the changes in FHR through the abdominal pressures against the strain gauge result- wall ing from the change in abdominal wall ii. Internal FHR contour a) Via FSE (1) Records contraction interval and b) Directly measures fetal duration heartbeat by measuring (2) Cannot determine intensity of the R-to-R interval during contractions heartbeats b. Palpation c) Indications include in- c. IUPC ability to externally monitor, fetal distress, • Fetal positions during birthing process meconium stained fluid 1. Mechanisms of labor and cardinal movements e. Direct fetal testing based on occiput anterior (OA) position (1) Fetal scalp sampling a. Left occiput anterior (LOA) is the most (a) Small amount of fetal blood is ob- common position of birth tained from the fetal scalp for pH b. Position and appropriate cardinal move- testing to rule out acidosis ments are facilitated in the gynecoid pelvis (b) Limiting factors c. Cardinal movements of labor i. Inadequate cervical dilation (1) Descent—usually in the ROA position, ii. Fetal head too high if engagement occurs during labor iii. Intact membranes (2) Flexion—vertex begins partially iv. Sampling errors due to devel- flexed, is completely flexed when oping caput or hematoma reaches pelvic floor, changing present- (c) Results ing diameter to suboccipitobregmatic i. Normal, more than 7.25 of 9.5 cm ii. Prepathologic, 7.20–7.25 (3) Internal rotation—rotation of 45° to iii. Pathologic, less than 7.20 OA allows the head to maximize the (d) Results are time limited and must anterior posterior diameter of the gy- be repeated every 20–30 minutes necoid pelvis if indications of distress persist (4) Extension—fulcrum of the neck under (e) Validity and reliability are the symphysis pubis allows birth of questionable the head (2) Fetal scalp stimulation (5) Restitution—vertex reassumes the ori- (a) During vaginal examination, fetal entation of a 90° angle with the shoul- head is stimulated ders as the shoulders begin entering (b) Expected result should be FHR ac- the AP diameter celeration of more than 15 beats (6) External rotation—as head rotates, off baseline for more than 15 shoulders complete the remainder of seconds the rotation to allow delivery in direct (c) Expected result correlates to fetal anterior posterior position pH of more than 7.20 2. Mechanisms of labor and cardinal movements (d) Cannot be reliably performed based upon occiput posterior (OP) position during deceleration or bradycar- a. Incidence of OP presentation is 15–30% dia; must wait for FHR recovery b. Right occiput posterior (ROP) is five times (e) Validity and reliability not well more common than left occiput posterior established c. More common in android and anthropoid (3) Fetal pulse oximetry pelvis (a) Provides ongoing measure of fetal d. 90% of OP presentations rotate to OA via oxygenation long arc rotation of 135° (ROP to ROT to (b) Research indicates no change ROA to OA) in rate of Cesarean section e. Short arc rotation of 45° results in direct with knowledge of fetal oxygen OP or deep transverse pelvic arrest saturation f. Cardinal movements (1) Descent—head enters pelvis in an oblique angle Management of the Second Stage of Labor 173

(2) Flexion does not occur until the head (3) Diaphoresis meets the pelvic floor, unflexed head (4) Nausea and vomiting can cause cephalopelvic dispropor- b. Bladder status tion (CPD) (1) Bladder distention can compromise (3) Internal rotation—head must rotate pelvic capacity 135° (2) Inability to void may require (4) Extension—once rotation is complete, catheterization head can be born by normal extension (3) Prevent problem by having client void (5) Restitution—may be delayed due when full dilatation approaches to the slower rotation of the fetal 3. Behaviors and coping ability shoulders a. Assessment of maternal fatigue (6) External rotation—as rotation occurs, b. Coping ability fetus rotates shoulders to the c. Response to pain and pressure anterior–posterior diameter of the 4. Pain control outlet to facilitate birth a. Evaluate level of sensation in epiduralized client to determine if anesthetic level is • Emotional support hindering pushing efforts 1. Psychological b. Pudendal anesthesia may be necessary as a. Calm environment fetal descent occurs causing perineal dis- b. Perception of safety and support for tention and pain mother and baby 5. Expulsive effort c. Maintenance of privacy and modesty a. Client should be coached to achieve effec- d. Participation in the plan of care tive pushing effort 2. Role of the labor support person b. Assessment of which type of pushing is a. Reinforcement of and positive encourage- most effective for the client ment for the laboring woman (1) Open glottis physiologic pushing b. Participation in the birth process (2) Closed glottis “Valsalva” pushing (1) Providing oral fluids and/or ice chips c. Client should be instructed to pant at the (2) Encouraging position changes time of crowning; “control the mother, not (3) Relaxation techniques the head” (4) Massage 6. Integrity of the perineum (5) Coaching with breathing techniques a. Maternal preference is generally avoidance of episiotomy Â Management of the Second b. Contributing factors to need for Stage of Labor episiotomy (1) Fetal malposition • Begins with complete dilatation and ends with the (2) Anticipation of large baby birth of the infant (3) Anticipation of shoulder dystocia (4) Poor distensibility of the perineal • Maternal status tissues 1. Vital signs (5) Difficulty in maintaining adequate a. BP every 15 minutes in low-risk women, control of client’s expulsive efforts every 5 minutes in high-risk women (1) BP must be taken between • Fetal status contractions 1. Vaginal examination (2) BP can be elevated 10 mm Hg in the a. Evaluation of descent with pushing effort second stage of labor due to pushing b. Normalcy of fetal position and adaptation effort to the maternal pelvis b. Pulse and respiratory rate every hour (1) Molding/caput succedaneum c. Temperature every 2 hours (2) Synclitism vs asynclitism 2. Hydration and fluid status (3) Appropriate rotation to facilitate a. IV or oral fluids should be encouraged due delivery to 2. FHR monitoring (1) Increased metabolism a. Need for increased frequency of FHR (2) Increased respiratory efforts/ evaluation hyperventilation of transition (1) Evaluation at least every 15 minutes 174 Chapter 6 Intrapartum and Postpartum

(2) More commonly every 5 minutes or c. Flexion—occurs when the fetal head after each contraction meets the resistance of the pelvic floor b. Periodic changes (early and variable de- during descent and forces the smaller sub- celerations) in FHR common occipitobregmatic diameter to enter the (1) Decelerations secondary to head pelvis first compressions d. Internal rotation—causes the anteropos- (2) Not indicative of acute fetal distress terior diameters of the fetal head and the maternal pelvis to align, most commonly • Pain relief causing the occiput to rotate to the ante- 1. Breathing techniques rior portion of the pelvis a. Controlled breathing as contraction be- e. Extension—mechanism by which the birth gins and ends assists in focusing efforts of the fetal head occurs; the fetal head fol- b. Promote relaxation between pushing lows the curve of Carus; the suboccipital efforts region of the fetal head pivots under the 2. Narcotic analgesia maternal pubic symphysis a. Should not be given within 1 hour of birth f. Restitution—rotation of the head 45° and b. Can cause respiratory depression in the realignment 90° to the shoulders neonate g. External rotation—occurs as the shoulders 3. Regional anesthesia rotate 45° bringing the shoulders into the a. Effectively lessens the pain and pressure anteroposterior diameter of the pelvis; the sensations of the second stage head also rotates another 45° b. Can lengthen second stage secondary to h. Birth of the body occurs by lateral flexion pelvic musculature relaxation and de- of the shoulders via the curve of Carus creased pressure sensations c. Pudendal—lidocaine 1–2% up to 10 cc on Â Delivery Management each side (1) Provides dense nerve block to the • Maintenance of pelvic integrity perineum 1. Anatomy (2) Does not inhibit pushing efforts a. Pelvic floor musculature (3) Needs to be timed well for best anes- (1) Function to support pelvic organs thetic effect (2) Aids in the anterior rotation of the fe- (a) Primiparas when vertex is at +2 tus during pelvic descent and birth (b) Multiparas shortly before com- (3) Consists of two muscle groups plete dilation (a) The levator ani, made up of: 4. Local anesthesia i. Pubococcygeus, made up of: a. Perineal infiltration—lidocaine 1–2% up to a) Pubovaginalis 10 cc in divided dosing b) Puborectalis (1) Used prior to cutting of an episiotomy c) Pubococcygeus proper (2) For repair of episiotomy or ii. Illiococcygeus laceration(s) (b) Coccygeus b. Perineal musculature • Emotional support (1) Perineum is divided into two triangles 1. Encouragement and is more superficial than the pelvic 2. Participation of labor support persons floor musculature 3. Adherence to birth plan (a) Anteriorly as the urogenital triangle • Cardinal movements of labor i. Superficial transverse 1. Eight basic movements that take place to allow perineal muscle birth in vertex presentation ii. Ischiocavernosus muscle a. Engagement—biparietal diameter of fetal iii. Bulbocavernosus head passes through pelvic inlet iv. Deep transverse perineal b. Descent—occurs secondary to forces of muscle uterine contractions, change in the tone of (b) Posteriorly as the anal triangle pelvic musculature and maternal pushing i. Sphincter ani externus ii. Anococcygeal body Delivery Management 175

(2) Separation is the transverse perineal (5) Evaluate adequacy of incision; repeat muscles and the base of the pelvic if indicated floor musculature b. Mediolateral episiotomy—generally used 2. Factors interfering with perineal integrity if patient has a short perineum to avoid a a. Size of fetus laceration into the anal sphincter b. Distensibility of perineum (1) Used much less frequently in US—less c. Control of expulsive efforts than 10% d. Operative delivery modalities, i.e., forceps (2) Same procedure except that the direc- or vacuum extraction tion of the scissors is a 45° angle from e. Occiput posterior position the base of the introitus directed ei- f. Use of lubricants ther right or left g. Maternal position for birth (3) The angle of the incision should be h. Episiotomy (median or mediolateral) aimed toward the corresponding 3. Strategies to minimize perineal trauma ischial tuberosity a. Antepartum perineal massage (4) Much more difficult to repair (1) Begin at 36–37 weeks 3. Lacerations (2) Increases elasticity and maternal tol- a. First degree—involves the vaginal mucosa, erance to perineal stretching posterior fourchette, and perineal skin b. External perineal massage from the time b. Second degree—involves same structures of perineal distension as above plus perineal muscles c. Warm compresses during second stage c. Third degree—involves same structures as (1) Increases circulation to perineum a second degree plus tearing through the (2) Promotes elasticity entire thickness of the rectal sphincter (3) Assists in the relaxation of the d. Fourth degree—involves all the structures musculature as above plus tearing of the anterior rectal d. Lateral positioning for birth wall e. Counter pressure to maintain flexion of 4. Repair the fetal head during birth a. Fundamentals of repair f. Education of the mother regarding the im- (1) Use of aseptic technique portance of controlled delivery of the head (2) Adequate anesthesia g. Support of the perineum at the time of (3) Visibility through good hemostasis birth (this is controversial, some providers (4) Appropriate suture material including adopt a “hands-off” approach to birth) needle size (5) Minimize local tissue trauma through • Episiotomy—surgical incision performed to en- gentle and limited blotting large the vaginal opening to allow delivery of the (6) Minimize the amount of suture used fetal head (7) Good approximation of tissues de- 1. Anatomy creasing dead space a. Muscles cut during median episiotomy b. Suture material (1) Bulbocavernosus (sphincter vaginalis) (1) Chromic catgut is the most common (2) Ischiocavernosus suture material (3) Superficial and deep transverse (2) Vicryl is alternately used for repair perineal muscles (3) Suture gauge 2. Technique (a) 3-0 chromic catgut a. Median episiotomy i. Vaginal mucosa (1) Place index and middle fingers, ii. Subcutaneous tissue slightly separated and palm side iii. Subcuticular tissue down, in vagina (b) 4-0 chromic catgut for finer (2) Insert scissors into the introitus in repairs an up and down position with one i. Periurethral blade placed externally and one blade ii. Periclitoral placed internally iii. Anterior wall of the rectum (3) Depth of insertion should correspond (c) 2-0 chromic catgut for areas re- to the length of intended episiotomy quiring more tensile strength (4) Cut tissue in one motion deliberately i. Vaginal wall lacerations and purposefully ii. Cervical lacerations 176 Chapter 6 Intrapartum and Postpartum

iii. Deep interrupted sutures for 7. Need for additional personnel, i. e., nurse, sec- repair of pelvic musculature ond midwife, consulting physician, pediatric (4) Needle selection provider (a) Atraumatic general closure nee- 8. Placement of newborn upon delivery dles are preferable 9. Timing of umbilical cord cutting (b) Small, fine GI needles should be used for fine stitching • Hand maneuvers for birth in the OA position (b) Cutting needles should not be 1. Apply counter pressure to the fetal head dur- used ing crowning to maintain flexion and control c. Mechanisms of repair of median epi- extension using nondominant hand siotomy or second-degree laceration 2. If using perineal support, place thumb and in- (1) Inspection of tissues to assess depth dex finger laterally on the distended perineum and extent of laceration with palmar surface supporting perineal body (2) Identify all appropriate anatomical 3. Control birth of head during extension structures 4. After birth of head, slide fingers of dominant (3) Begin repair approximately 1 cm be- hand around fetal head to posterior neck to yond the apex of the laceration to the feel for umbilical cord vaginal mucosa 5. If nuchal cord is present: (4) Close the mucosa using continuous a. Gently slip over baby’s head if loose locked stitches to the level of the hy- b. If not easily reduced over the head, slip menal ring cord over baby’s shoulders as the baby is (5) Pass needle under hymenal ring and born continue using blanket stitches (non- c. If tight, doubly clamp and cut and unwind locked) to the level of the bulbocaver- cord before delivery of the shoulders nosus muscle 6. Suction baby’s mouth and nose with bulb sy- (6) Repair bulbocavernosus muscle with ringe, if needed a crown stitch using a separate 2-0 7. After restitution and external rotation, place chromic, if desired the palmar surface of each hand laterally on (7) If laceration is deep, consider several the baby’s head deep interrupted stitches using 2-0 8. With gentle downward traction, and maternal chromic pushing effort, deliver anterior shoulder. Some (8) Using the 3-0 chromic suture again, recommend waiting for the next contraction repair the perineal fascia with con- 9. With upward traction, lift the baby’s head to- tinuous stitching to the perineal apex ward ceiling to deliver the posterior shoulder (9) Using mattress stitches, perform sub- while observing the perineum cuticular closure 10. Glide posterior hand along head and poste- (10) At the level of the hymenal ring, bury rior shoulder to control the posterior arm as it the suture and tie off delivers 11. As the baby delivers, maintain posterior hand • Management decisions for birth under the baby’s neck with the baby’s head 1. Timing for the preparation of the birth related supported by the wrist and forearm to location, i. e., moving to a delivery room 12. The anterior hand follows the body of the baby 2. Delivery position for birth during birth and grasps the lower leg of the a. Semi-sitting baby b. Squatting 13. Rotate the baby into the football hold with the c. Lateral head in the palm, and the legs between what d. Hands and knees was the posterior arm and attendant’s body e. Supine or lithotomy (least appropriate, 14. Keep the baby’s head below its hips, and but commonly used) slightly to the side, to facilitate drainage and 3. Determine need for an episiotomy suctioning 4. Need for/type of additional anesthesia/ analgesia • Suctioning—ensuring a clear airway 5. Use of perineal support during birth 1. Routine suctioning of nasal and oral passages 6. Use of the Ritgen maneuver—assistance, if has not been assessed in clinical trials so its needed, in delivering fetal head by applying value is uncertain upward pressure to the fetal chin through the 2. Most healthy babies can clear their airways perineum during extension with no additional help Management of the Third Stage 177

3. Bulb syringe 5. Management of placenta delivery a. Generally sufficient to clear oral and nasal a. Obtain cord bloods after clamping of the passages of fluid and mucus after birth cord b. Minimize pharyngeal stimulation and tis- b. Inspect cord for number of vessels sue trauma c. Guard the uterus while waiting for pla- c. After birth of baby, sometimes additional centa separation suctioning is necessary (1) No fundal massage before separation 4. DeLee mucous trap suctioning (2) No traction on umbilical cord until a. Indicated for meconium stained amniotic separation fluid d. Use modified Brandt-Andrews to assess b. Occurs after birth of head to clear oro- and for separation nasopharynx e. When separation has occurred, use c. Mucous trap allows amount and color of Brandt-Andrews maneuver to stabilize the fluid to be assessed uterus and control cord traction to deliver d. Mother should be instructed to pant and the placenta not push during this suctioning f. May have mother push to assist expulsion g. Deliver placenta via the curve of Carus Â Management of the h. If membranes are trailing behind the pla- Third Stage centa, carefully deliver membranes by: (1) Using a Kelly clamp or sponge stick • Begins with delivery of the infant and ends with clamp onto membranes, gently apply the delivery of the placenta lateral and outward traction (2) Holding the bulk of the placenta and • Delivery of the placenta twisting the placenta over and over 1. Timing—generally 5–30 minutes after the birth until the membranes are delivered 2. Method of placental separation (3) Inspecting placenta and membranes a. Placenta separates from the uterine wall for completeness due to change in uterine size b. Hematoma forms behind the placenta • Appropriate diagnostic tests along the uterine wall 1. Cord blood c. Separation of the placenta completes a. Fetal blood type and Rh d. Descent of the placenta to the lower uter- b. Direct Coombs testing ine segment or vagina 2. Maternal blood e. Expulsion a. Kleihauer-Betke stain, if mother is Rh 3. Signs and symptoms of placental separation negative a. Sudden increase in vaginal bleeding b. CBC, if hemorrhage suspected b. Lengthening of the umbilical cord c. Uterine shape from discoid to globular • Use of oxytocics d. Uterus rises in the abdomen 1. Oxytocin 4. Mechanisms of placental delivery a. Used prophylactically against postpartum a. Schultz hemorrhage (1) Presents at the introitus with fetal side b. Causes intermittent uterine contractions showing to decrease uterine size and the placental (2) More common than Duncan bed exposure (3) Separation is thought to occur cen- c. Administration trally first (1) Intravenous (4) Majority of bleeding is contained (a) 20 units in 1000 cc of IV fluid with b. Duncan first liter running as rapidly as (1) Presents at the introitus with maternal possible, second liter at 150 cc/hr side showing (b) Can use up to 30 units per liter (2) Less common (c) Total no more than 100 units (3) Separation occurs initially at placental (2) Intramuscular—10 units intramuscu- margin larly if no IV access (4) Bleeding is more visible 2. Methylergonovine (5) Higher incidence of hemorrhage due a. Causes a sustained, tetanic uterine to incomplete separation of placenta contraction 178 Chapter 6 Intrapartum and Postpartum

b. Can be used emergently as one-time dos- 3. Significance of scoring ing or as a series of doses for sustained a. One-minute Apgar scoring used to deter- effect mine level of resuscitation required c. Contraindicated in hypertensive pa- b. Five-minute Apgar scoring has a relation- tients because it causes peripheral ship to neonatal morbidity and mortality vasoconstriction (1) Apgars of less than 7 at 5 minutes in- d. Administration dicate need for pediatric involvement (1) Intramuscular—0.2 mg IM, can be re- (2) Apgars of less than 4 at 5 minutes cor- peated once relate with neonatal mortality (2) Oral (3) Low Apgar scores by themselves are (a) Generally given as a series of not predictive of later neurologic 6 doses over the first 24 hours dysfunction postpartum c. Not as valid an assessment for preterm (b) 0.2 mg orally every 6 hours infants 3. Carboprost a. Used only in severe hemorrhage situations • Indications for pediatric involvement b. Administration 1. Any condition or circumstance that may com- (1) 250 mcg promise the adaptation of the neonate to ex- (2) Can be given IM or intramyometrially trauterine life a. Obstetrical conditions • Placental abnormalities and variations (1) Known IUGR 1. Battledore placenta—peripheral cord inser- (2) Birth prior to 37 weeks tion, at placental margin (3) Oligohydramnios 2. Succenturiate lobe (4) Maternal systemic disease a. Most common abnormality—occurrence (5) Congenital abnormalities 3% b. Intrapartum conditions b. Accessory placental lobe within the fetal (1) Narcotic analgesia at less than 1 hour sac that had continuous vascular connec- prior to birth tions with main placenta (2) Chorioamnionitis c. Can cause retained placenta or (3) Operative delivery including Cesarean hemorrhage section 3. Velamentous cord insertion (4) Nonreassuring fetal heart rate a. Cord insertion into fetal sac, not directly into placental bed, generally 5–10 cm Â Special Considerations and away from placenta Deviations from Normal b. Can cause shearing of blood vessels during labor or delivery of placenta, causing • Premature labor hemorrhage 1. Definitions c. More common in multiple gestation a. Premature labor—onset of regular uterine 4. Circumvallate placenta contractions between 20 and 37 weeks’ a. Opaque ring of fibrous-appearing tissue gestation with spontaneous rupture on fetal side of the placenta, caused by a of membranes or progressive cervical double layer of chorion and amnion changes (ACOG, 2003). b. Can be seen in IUGR pregnancies but usu- b. Premature birth—delivery prior to 37 ally of no clinical significance weeks’ gestation c. Term birth—delivery between 37 and 42 Â Management of Immediate weeks’ gestation Newborn Transition—see also d. Small for gestational age (SGA)—birth chapter 5 weight at less than 10th percentile for gestational age; corresponds to IUGR • Apgar scoring 2. Incidence—approximately 10% of all births in 1. Devised in 1952 by Dr. Virginia Apgar to iden- the United States tify infants requiring assistance adapting to 3. Etiology the extrauterine environment a. Idiopathic and multifactorial; in most 2. Comparable to the biophysical profile scoring cases the cause of premature labor is in utero unknown b. Maternal factors Special Considerations and Deviations from Normal 179

(1) Systemic diseases 8. Management—consultation with physician (a) Pregnancy-induced hypertension regarding need for transfer of care versus (b) Renal disease comanagement (c) Autoimmune disease a. Nonpharmacologic (d) Infection (1) Hydration (2) Structural uterine abnormalities (2) Left-lateral bed rest (a) Müllerian defects b. Tocolysis—generally used to delay birth (b) Fibroids more than 48 hours in order to give ste- (3) Overdistended uterus roids to hasten lung maturity (a) Multiple gestation (1) Contraindications to tocolysis—any (b) Polyhydramnios conditions causing a hostile uterine (4) Cervical incompetence environment (5) History of premature labor (a) Placental abruption (6) Low socioeconomic factors (b) Chorioamnionitis c. Fetal factors (c) Severe preeclampsia (1) Premature rupture of membranes— (d) Placenta previa implicated in 30% of all premature (e) Fetal distress labor (f) Lethal fetal anomalies (2) Fetal anomalies (g) IUGR without interval growth (3) Placental insufficiency (2) Beta agonists (terbutaline, ritodrine) 4. Signs and symptoms (a) Drug action—interferes with a. Menstrual-like cramping with increasing smooth muscle contractility frequency and intensity (b) Side-effects b. Pelvic pressure, especially suprapubic i. Palpitations/tachycardia c. Backache ii. Tremors d. Passage of amniotic fluid iii. Anxiety e. Change in the character of vaginal iv. Hyperglycemia secretions v. Hypokalemia f. Bloody show/spotting vi. Pulmonary edema g. Progressive cervical dilatation vii. Fetal tachycardia 5. Physical findings (c) Drug interactions a. Uterine contractions documented by EFM i. MAO inhibitors or palpation ii. Diuretics b. Cervical dilation on digital examination iii. Beta blockers c. Documented ruptured membranes (d) Contraindications 6. Differential diagnosis i. Use of drugs causing unto- a. Urinary tract infection/pyelonephritis ward interactions b. Round ligament pain ii. Underlying cardiac dis- c. Braxton Hicks contractions ease, especially conduction d. Renal colic disorders e. Appendicitis (e) Administration and dosing 7. Diagnostic tests to consider i. Routes—PO, SQ, SQ infusion a. Fern and/or nitrazine test if suspect rup- pump, IV ture of membranes ii. Terbutaline PO 2.5–5 mg, SQ b. Urinalysis with culture and sensitivity 0.25 c. Other tests for suspected infections— iii. Ritodrine PO 5–10 mg, IV Chlamydia, GC, wet prep rarely used any longer

d. Fetal fibronectin—collect before digital ex- (3) Magnesium sulfate (MgSO4) amination; recent sexual activity or blood (a) Drug action—acts on vascu- may affect results lar smooth muscle causing e. Ultrasound—cervical length and funnel- vasodilatation ing, placental location and status, bio- (b) Side-effects physical profile, and amniotic fluid index i. Flushing f. Amniocentesis—fetal surfactant and ii. Palpitations lecithin/sphingomyelin (L/S) ratio iii. Feeling of warmth g. CBC with differential iv. Lethargy v. Muscle weakness 180 Chapter 6 Intrapartum and Postpartum

vi. Dizziness c. Other management decisions vii. Nausea/vomiting (1) Group B streptococcal prophylaxis viii. Respiratory depression (a) Penicillin 5 million units IV fol- ix. Pulmonary edema lowed by 2.5 million units every (c) Drug interactions—calcium chan- 4 hours until delivery or negative nel blockers culture (d) Contraindications (b) Clindamycin as alternative ther- i. Use of calcium channel apy if allergic to penicillin blockers (2) Corticosteroid administration ii. Toxic effects at serum level of (a) Stimulates fetal lung maturity and more than 7 mg/dL possibly protection from intra- iii. Antidote is calcium gluconate ventricular hemorrhage (e) Administration and dosing (b) Dexamethasone 6 mg IM every i. Generally IV, can be given IM 12 hours for 4 doses ii. Loading dose 4–6 g in 100 cc (c) Betamethasone 12 mg IM 3 2 IVF over 20–30 minutes doses 24 hours apart iii. Initial maintenance dose (d) Should attempt to delay birth un- 2 g/hr til 24 hours post administration iv. If contractions continue, increase by 0.5 g/hr every 30 • Umbilical cord prolapse minutes to a max dose of 1. Definition—umbilical cord lies below or be- 4 g/hr side the presenting part; danger is compres- v. Maintain at effective level for sion of the umbilical cord, thus compromising 12 to 24 hours after contrac- the blood supply to the fetus tions stop 2. Etiology/incidence vi. No benefit for weaning when a. Presenting part does not fill the pelvic discontinued inlet; can occur with the rupturing of (4) Calcium channel blockers (nifedipine) membranes (a) Drug action—nonspecific smooth b. Incidence—1 in 400 pregnancies muscule relaxant; prevents influx 3. Signs and symptoms/physical findings of extracellular calcium ions into a. Umbilical cord visible at or outside myometrial cells; effect not spe- introitus cific to uterus b. Palpation of cord during vaginal (b) Side-effects examination i. Maternal hypotension c. Presumptive diagnosis of occult prolapse ii. Flushing if fetal distress occurs immediately follow- iii. Nausea/vomiting ing rupture of membranes (c) Drug interactions 4. Management i. Beta-agonists a. Elevate presenting part off cord by con- ii. Magnesium sulfate tinuous vaginal examination (d) Contraindications b. Assist mother into knee–chest position or i. Do not use in presence of steep left-lateral Trendelenburg intrauterine infection, mater- c. Do not attempt to manipulate the cord as nal hypertension, or cardiac this may cause cord spasm; if protruding, disease wrap loosely with warm normal saline- ii. Do not use in combination soaked gauze with beta-agonists or magne- d. Do not rely on cord pulsations as indicator sium sulfate of fetal status—obtain ultrasound if un- (e) Administration and dosing able to detect fetal heart tones i. Route—PO e. Immediately alert consulting physician ii. Initial dose of 10 mg and other staff of emergency

iii. If contractions continue, re- f. O2 at 10 L/min peat doses every 20 minutes g. Intravenous fluid bolus for total of 30 mg in 1 hour h. Monitor FHR iv. Once contractions decrease, i. Consider terbutaline for tocolysis may give 10 mg every 6 hours j. Prepare for Cesarean section or 30–60 mg sustained release dose per day Special Considerations and Deviations from Normal 181

• Placenta previa 5. Differential diagnosis—placenta previa 1. Definition—placenta is located over or very 6. Diagnostic testing—ultrasound confirmation near the internal os of condition of placenta a. Complete placenta previa—placenta com- 7. Management pletely covers the cervical os a. Complete abruption b. Partial placenta previa—cervical os par- (1) Notify consulting physician tially covered by placenta (2) Insert two large-bore IV catheters c. Marginal placenta previa—edge of pla- (3) Prepare for STAT C-section centa within 1 cm of cervical os (4) Obtain blood type and cross-match 2. Etiology/predisposing factors for blood products including clotting a. Increased parity factors b. Advanced maternal age (5) Trendelenberg position

c. Previous Cesarean section (6) O2 at 10 L/min d. Multiple gestation (7) Monitor fetal status 3. Signs and symptoms b. Partial abruption a. Painless vaginal bleeding during the third (1) IV access trimester 70–80% of the time (2) Monitor fetal status b. Bleeding with contractions 10–20% (3) Preparation in the event immediate c. Can be diagnosed before hallmark bleed surgical intervention is required with ultrasound 4. Physical findings—no digital vaginal exam un- • Shoulder dystocia til placenta location is known; contraindicated 1. Definition—difficulty in delivery of shoulders with placenta previa secondary to anterior shoulder becoming im- 5. Differential diagnosis—placental abruption pacted on the pelvic rim 6. Diagnostic testing—ultrasound confirmation 2. Etiology/risk factors 7. Management a. Gestational diabetes a. Acute bleeding requires emergency Cesar- b. History of macrosomic babies ean section c. Maternal obesity b. Otherwise dependent on severity of symp- d. Increased weight gain during pregnancy toms and gestational age e. Small/abnormal/contracted pelvis c. Bedrest and/or hospitalization usually f. Prior history of shoulder dystocia indicated g. Estimated weight of fetus 1 pound larger d. Rhogam for unsensitized Rh negative than previous infants if a multiparous mother woman e. Generally delivered by C-section 3. Incidence—less than 1% of all births 4. Morbidity and mortality • Placental abruption a. Maternal—extensive vaginal and perineal 1. Definition—premature separation of the pla- lacerations centa from the uterine wall prior to delivery of b. Fetal the fetus (1) Fractured clavicle 2. Etiology (2) Brachial plexus injury a. Maternal hypertension (3) Hypoxia/anoxia b. Severe abdominal trauma (4) Fetal death c. Sudden decrease in uterine volume such 5. Signs and symptoms as rupture of membranes with polyhy- a. “Turtle sign”—the immediate retraction of dramnios or multiple gestation the fetal head against the perineum after d. Cocaine use extension e. Previous abruption b. Delayed restitution or need for facilitated 3. Incidence restitution without descent a. 1 in 80 deliveries c. Inability to deliver anterior shoulder with b. Can be marginal abruption and not usual traction effort catastrophic 6. Management 4. Signs and symptoms/physical findings a. Anticipation of shoulder dystocia should a. With complete abruption, painful vaginal be an indication or signal of need for bleeding, uterine rigidity, shock emergency preparedness b. Less than complete abruptions have less b. Immediately have any physician paged severe presentations STAT c. Bleeding can be concealed 182 Chapter 6 Intrapartum and Postpartum

c. Notify other staff including anesthesia and e. Spontaneous vaginal breech delivery— the pediatrics team birth without additional external d. Perform McRobert’s maneuver—place assistance mother in exaggerated lithotomy position f. Assisted vaginal delivery (partial breech (knees to shoulders) extraction)—spontaneous delivery to the e. Have suprapubic pressure (not fundal umbilicus, remainder of the body deliv- pressure) applied while exerting down- ered with assistance ward traction on baby’s head while mother g. Total breech extraction—entire body ex- is pushing tracted by birth attendant f. Cut or extend episiotomy—controversial; 2. Incidence catheterize woman to empty bladder a. 3–4% at term g. Attempt to rotate shoulders to oblique and b. At 28 weeks, 25% of all fetuses are breech repeat McRobert’s maneuver and supra- c. Most convert to cephalic by 34 weeks’ pubic pressure—insert a hand on either gestation side of the fetal chest and attempt to ro- 3. Etiology/risk factors tate shoulders out of the anteroposterior a. Presentation possibly related to the fetus diameter accommodating to the shape of the uterus h. Attempt Wood’s screw maneuver (1) Preterm fetuses position the head in (1) Using the same techniques the upper portion of the uterus being (2) Rotate fetus 180° (keeping the back the larger portion of the body anterior) (2) At term, the largest part of the fetus is (3) If still impacted, continue rotation the head, thus causing it to descend another 180° into the pelvis i. Knee–chest position b. Maternal indications j. Deliver posterior arm (1) Gestational age (1) Insert hand behind posterior shoulder (2) Fibroids (2) Splint arm and sweep across abdo- (3) Uterine anomalies men and chest until the hand can be (4) Abnormal placentation grasped externally (a) Placenta previa k. Break the anterior clavicle—place thumbs (b) Cornual fundal implantation along clavicle and force clavicle outward; (5) Oligohydramnios/polyhydramnios controversial as have possibility of punc- c. Fetal factors turing lung or injuring subclavian vessels (1) Congenital anomalies—three-fold l. Zavanelli maneuver—rotate and flex head increase in anomalies with breech while replacing fetus into pelvic cavity fol- presentation lowed by immediate C-section; controver- (2) Short umbilical cord sial as associated with significant risk of 4. Morbidity/mortality infant morbidity and mortality a. Cord prolapse (1.5% of frank breech and 10% in other breech presentations) • Breech delivery—the elective vaginal delivery of b. Traumatic vaginal delivery infants in the breech presentation is no longer rec- (1) Largest part of the fetus is delivered ommended by the American College of Obstetri- last cians and Gynecologists. Vaginal delivery of breech (2) Head entrapment causing injury to presentation should be reserved only for breeches organs, brain, and skull that present emergently and when birth is essen- c. Increased perinatal morbidity and tially inevitable. mortality 1. Definition—delivery of infant presenting with 5. Management and treatment buttocks, feet, or knees a. Vaginal breech birth is a comanagement a. Complete breech—legs and thighs are situation flexed with buttocks presenting b. Criteria for candidates of vaginal breech b. Frank breech—legs extended on abdo- birth men with flexed thighs and buttocks (1) Frank breech presentation presenting; most common type of breech (2) EFW 2500–3800 g presentation (3) Flexion of the fetal head c. Footling breech—one or both feet c. Management decisions presenting (1) Continuous fetal monitoring d. Knee presentation—single or double (2) IV access knee(s) are presenting (most rare) Special Considerations and Deviations from Normal 183

(3) Use of oxytocin for protraction dis- occiput proximal to the spine; usually begins orders very controversial; generally labor as a brow presentation Cesarean section is indicated 2. Incidence 1 in 250 births, higher in multiparas (4) Generous episiotomy 3. Etiology (5) Empty bladder before second stage a. Can be an indicator of CPD (6) Should deliver as a double set-up in b. Multiple loops of nuchal cord operating room c. Tumors of the neck 6. Delivery sequence for partial breech extraction d. Anencephalic fetus a. “Hands off the breech” until the body is 4. Risk factors born to the umbilicus a. Can cause CPD because of the longer pre- b. Second provider should be maintaining senting diameter being obstructed in the head flexion through the abdominal wall pelvis during entire descent b. If mentum is not anterior, fetus is unable c. Wrap the body with a warm dry towel for to pass under the pubic symphysis remainder of birth 5. Diagnosis d. Pull down loop of cord a. During Leopold’s maneuver, occipital e. From this point on, the mother is in- bone is easily palpated and prominent; structed to push continuously head feels larger than expected f. If the legs have not delivered spontane- b. During vaginal examination, facial land- ously, they should be gently guided out of marks can be palpated the vagina 6. Management g. Downward traction then applied with the a. Review clinical pelvimetry to assure pelvic hands to baby’s hips with thumbs in the adequacy sacroiliac region to encourage delivery of b. Confirm position is mentum anterior as the anterior scapula mentum posterior is contraindicated for h. If necessary, provider can encourage rota- vaginal birth tion to LSA c. Collaborate with consulting physician if i. Attendant delivers anterior arm by mov- protraction disorder occurs ing hand up the infant’s back and over the d. Pediatric attendance at the birth top of the anterior shoulder sweeping the arm down across the chest and under the • Twin gestation—intrapartum twins are always a pubis with attendant’s finger collaborative management situation j. The infant is raised so the posterior arm 1. Definitions—multiple gestation with two fe- can be delivered in the same manner tuses in the uterus k. The back should spontaneously rotate a. Monozygotic twins—zygotic division be- anteriorly tween 4 and 8 days l. Employ the Mauriceau-Smellie-Veit ma- (1) Identical twins neuver to maintain flexion of the head (2) One placenta (1) With dominant hand palmar side up, (3) Generally one chorion, two amnions place extended index finger in baby’s b. Dizygotic twins mouth with chest and body resting on (1) Fraternal twins palm and legs straddling forearm (2) Two placentas (2) The other hand is placed on top of the (3) Two chorions, two amnions baby with the index finger on one side 2. Incidence and middle finger on the other side of a. Monozygotic twinning rate stable at 1 per the neck extending over the shoulder 250 births for traction b. Dizygotic twinning rates increasing due to m. Again apply downward traction until the assisted reproductive technologies suboccipital region (the hairline is seen 3. Predisposing factors coming under the pubic symphysis) a. Family history n. Now apply upward traction while elevat- b. Ovulation induction/in vitro fertilization ing body to deliver the head via the curve c. Sub-Saharan African descent of Carus 4. Diagnosis a. Size larger than dates • Face presentation b. Auscultation of more than one fetal heart 1. Definition—cephalic presentation with at- beat titude of head in complete extension with c. Abnormal Leopold’s maneuver findings d. Ultimate diagnosis by ultrasound 184 Chapter 6 Intrapartum and Postpartum

5. Morbidity (2) Placenta increta—further extension a. Premature labor and birth into the myometrium with penetra- b. Premature rupture of membranes tion into the uterine wall c. Malpresentation of second twin (3) Placenta percreta—further extension d. Cord prolapse through the uterine wall to the serosa e. Operative delivery for second twin layer f. SGA and IUGR babies 4. Management g. Twin-to-twin transfusion a. Facilitate usual methods of placental 6. Management decisions separation a. Physician should be collaborating for all (1) Allow baby to nurse/nipple intrapartum decisions and present for the stimulation birth (2) Assist mother into squatting position b. Ultrasound confirmation of presentation (3) Empty maternal bladder c. Intravenous catheter insertion (4) Injection of oxytocin solution (10 d. Type and screen blood upon admission; units in 20 cc normal saline) into the some facilities require type and cross- umbilical vein match b. If third stage is more than 30 minutes, e. Continuous fetal monitoring consider that placenta is retained; notify f. Anesthesia presence for birth consulting physician g. Pediatric attendance for birth c. Management in preparation for consulting h. Ultrasound machine in delivery room physician i. Bladder should be emptied prior to (1) Monitor for bleeding or shock pushing (2) Insert IV if none in place 7. Management (3) Prepare mother for manual placenta a. Birth of the first twin in usual fashion—if removal nuchal cord is present, DO NOT cut cord, (4) Notify anesthesia attempt birth with cord intact b. Upon delivery, clamp cord and transfer • Postpartum hemorrhage baby to pediatric team 1. Definition—blood loss of more than 500 cc c. Via fundal pressure, assistant can guide a. Immediate—within first 24 hours second twin into the pelvis depending b. Delayed—after the first 24 hours but upon presentation within the first 6 weeks d. Confirm presentation of second twin 2. Etiology based on ultrasound a. Predisposing factors e. Timing of delivery is dependent upon fetal (1) History of postpartum hemorrhage status (2) Grand multiparity f. Oxytocin augmentation can be used if (3) Overdistended uterus contractions do not resume (a) Multiple gestation g. Birth of second twin (b) Polyhydramnios h. Observe for postpartum hemorrhage (c) Macrosomia b. Intrapartum factors • Retained placenta (1) Induced or augmented labor 1. Definition—placenta that has not separated (2) Prolonged labor from uterine wall after 60 minutes (3) Precipitous labor 2. Predisposing factors (4) Uterine atony a. Premature delivery 3. Management b. Chorioamnionitis a. Notify consulting physician c. Prior Cesarean section b. Uterine massage, if related to atony d. Placenta previa c. Medications e. Grand multiparity (1) Oxytocin 3. Etiology (2) Methylergonovine a. Structurally abnormal uterus (3) Carboprost b. Abnormal placentation—incidence has d. IV fluid bolus increased with increasing Cesarean rates e. Bimanual compression if other measures (1) Placenta accreta—adherence to myo- unsuccessful metrium due to partial or total ab- f. Consider manual removal of placenta, if sence of decidua not delivered The Normal Postpartum 185

g. Consider vaginal, sulcus, cervical lacera- c. Flow increases with additional activity ini- tions as cause of bleeding tially but decreases progressively over the puerperium Â The Normal Postpartum d. Total amount 150 to 400 cc 3. Cervix, vagina, and perineum • Data base a. Cervix 1. Pregnancy highlights (1) Initially appears edematous, dilated a. Gravidity/parity 3–4 cm and bruised b. Obstetrical history (2) At 7 days, 1 cm dilated and by day c. Pertinent medical history 10–12, fingertip dilated d. Pertinent pregnancy diagnostic tests (3) Nonpregnant appearance and texture (1) Blood type and Rh 1 month postdelivery (2) Rubella titer status (4) Multiparous—at completion of invo- (3) Hepatitis B status lution, external os does not return to (4) HIV status its prepregnant appearance; remains 2. Birth information somewhat wider with a transverse a. Type of birth opening resembling a “fish-mouth” (1) Type of episiotomy/laceration b. Vagina (2) Type of operative birth (1) Initially edematous, relaxed, some- (3) Reason for interventions times bruised with decreased tone b. Type of anesthesia/analgesia (2) Rugae return by 3 weeks postpartum c. Sex of baby c. Perineum d. Weight of baby (1) Edematous with decreased tone im- e. Apgar scores mediately after birth f. Method of feeding (2) Laceration and episiotomy repair should be well approximated • Physiologic and anatomical changes (3) Skin should appear healed at 7 days 1. Uterus with only linear scarring at 6 weeks a. Immediately contracts to 1–2 finger- 4. Breasts breadths below the umbilicus but by 12 a. Colostrum is produced upon birth of baby hours postdelivery, is at the level of the b. Engorgement occurs approximately 72 umbilicus hours after birth b. By 2 weeks, no longer palpated (1) Human milk production begins in the abdominally upper-outer milk glands c. By 6 weeks, returns to slightly larger than (2) Filling then occurs medially and prepregnant size inferiorly d. Involution—process of the uterus return- (3) Distention and stasis of vascular and ing to the prepregnant state lymphatic circulation causes engorge- (1) Involves three steps ment as the ducts, lobules, and alveoli (a) Contraction of the uterus fill with milk (b) Autolysis of myometrial cells c. “Let-down” reflex develops within the first (c) Regeneration of the epithelium 1 to 2 weeks (2) Results from cell size reduction not 5. Hematologic cell number reduction a. Within the first hours post delivery, car- 2. Lochia diac output increases 60–80% a. Consists of the breakdown of myometrial b. Over first 48 hours, as diuresis occurs placental bed eschar and decidual cells plasma volume decreases and cardiac out- b. Three stages of discharge put normalizes by 2 weeks (1) Rubra—first 24–72 hours, superficial c. Transient bradycardia occurs in first 1–2 layer of decidua sloughs with debris days postpartum and necrotic remains of the placenta d. Can have transient leukocytosis in initial (2) Serosa—from day 3 to day 10, serous 48 hours to serosanguinous secretion 6. Renal system changes (3) Alba—until cessation of flow, yellow- a. Diuresis occurs within first 5 days due to ish or white discharge extravascular fluid shifts 186 Chapter 6 Intrapartum and Postpartum

b. Bladder can be hypotonic and edema- d. Blood pressure tous immediately after the birth; resolves (1) Remains normal within 24 hours (2) Blood pressure of greater than 140/90, 7. Weight loss evaluate for postpartum preeclampsia a. Weight loss of up to 15 pounds initially, (3) Blood pressure of less than 90/60, may return to prepregnant weight by 6 evaluate causes of hypotension weeks postpartum (a) Blood loss b. Weight loss facilitated by breastfeeding (b) Medication reaction secondary to increased caloric requirements (350 calories more per day) Â Assessment of Maternal 8. Gastrointestinal changes Response to Baby a. Peristalsis decreased in first 24 hours; increases risk of ileus after Cesarean section • Early attachment and bonding b. Liver enzymes including AST and ALT re- 1. First hour after birth—maternal sensitive turn to prepregnant values within 2 weeks period 9. Abdominal changes a. Initial bonding occurs during this time a. Diastasis recti found in 75–80% of postpar- b. Mother and baby should not be separated tum women—if diastasis after the post- c. Signs of attachment partum period, future pregnancies will (1) Initial touching with fingertips pro- lack sufficient abdominal support leading gressing to entire hand with stroking to back pain and massaging baby b. Striae common in most postpartum (2) “En face” posturing between mother women and baby 10. Endocrine (3) Using high-pitched speaking voice a. Breastfeeding women (4) Bonding is facilitated during the first (1) Lactation is stimulated and prolactin hour of life, the quiet alert phase for secreted the baby (2) By negative feedback mechanism, 2. Attachment ovulation and menstruation are inhib- a. Privacy should be arranged for parents as ited by increased prolactin and result- soon as possible after the birth ing estrogen suppression b. Attachment is a progressive process dur- (3) Resumption of menses is variable with ing the initial postpartum period supplementation or food introduction (a) Generally ovulation occurs 14–30 • Psychological response to childbearing days after weaning 1. Positive reactions (b) First menses 14 days later a. Sense of achievement in giving birth (c) Mean time to ovulation is 190 b. Sense of empowerment and strength days c. Thrill of new baby b. Nonbreastfeeding women 2. Negative reactions (1) Prolactin levels fall after initial a. Sense of loss if birth was not as anticipated engorgement b. Feeling of mistrust of body if unable to (2) Hormonal shifts to stimulate ovula- complete the birth process or if birth was tion begin approximately 3–4 weeks premature postpartum (3) First menses at 6–8 weeks postpar- • Postpartum blues and depression tum, 70% by 12 weeks 1. Postpartum blues 11. Vital signs a. 80% of all women a. Temperature b. Begins within 3–5 days of birth, concur- (1) Stabilizes during the first 24 hours rent with profound hormonal shifts postpartum c. Very labile emotions (giddiness thru sad- (2) Should not be over 100.4°F ness and crying), usually defy explanation b. Pulse d. Generally time limited over 1–2 weeks (1) Should remain within normal limits e. Supportive, sensitive care is usually all that (2) More than 100 bpm could be signifi- is required cant for infection or posthemorrhage 3. Postpartum depression/psychosis anemia a. Approximately 10% incidence of depres- c. Respiratory rate—remains normal sion, true postpartum psychosis in less than 1% of women Management Plan for the Postpartum Period 187

b. Onset of symptoms around 4–6 weeks, 4. Abdominal examination generally worsen over time a. Uterine fundal examination c. Symptoms are the same as for major de- b. Abdominal musculature pression in nonpostpartum woman c. Bladder status d. Symptoms can incapacitate women 5. Perineum (1) Unable to perform activities of daily a. REEDA (redness, ecchymosis, erythema, living drainage, and approximation) (2) Can have suicidal or homicidal b. Lochia ideation c. Status of lacerations/episiotomy (3) Apathy towards themselves and their d. Hemorrhoids babies 6. Extremities e. Symptoms do not improve over time; a. Calf tenderness and warmth more likely they worsen b. Edema f. Diagnosis—screen all postpartum women c. Varicosities for depression with Edinburgh Postnatal 7. Pain assessment Depression Scale; rule out postpartum 8. Emotional status thyroiditis, anemia, infection, sleep deprivation • Diet—after normal birth, regular diet immediately g. Require psychiatric evaluation and treat- postpartum ment usually including medication h. Women previously treated for clinical • Activity depression have increased risk of postpar- 1. Out of bed as desired tum depression 2. Should be escorted out of bed for the first i. Psychosis—disorganized thinking, be- time, secondary to risk of syncope havior, speech; auditory or visual perceptual disturbances; delusions—medical • Hygiene emergency 1. Should receive instructions in perineal care 2. Topical anesthetics, if indicated • Grief 1. Can be related to losing a pregnancy, having a • Contraception viable baby but not meeting expectations, i.e., 1. Nonbreastfeeding women generally have men- congenital anomalies or organic cause such as ses prior to the 6-week visit; therefore, birth postpartum depression control should be initiated prior to discharge 2. Stages of grief 2. Hormonal methods (combination hormonal a. Shock methods—pills, patch, vaginal ring; progestin- b. Suffering only methods—progestin-only pills, depo me- c. Resolution droxyprogesterone DMPA, subdermal implant) a. Combination hormonal methods not in- Â Management Plan for the dicated for breastfeeding women initially Postpartum Period postpartum b. DMPA, progestin-only pills, and subder- • Evaluation of maternal well-being mal implant good choices for breastfeeding women • Chart review 3. Barrier methods a. Cervical cap/diaphragm—cannot be fit • History until involution is complete 1. Family history b. Male and female condoms—can be used 2. Past medical, surgical, and obstetrical history immediately 3. Review of prenatal care 4. Spermicides 4. Review of intrapartum period a. Foam, cream, vaginal contraceptive film, 5. Infant data sponge b. Should delay use until lochia ceases • Physical examination 5. Intrauterine contraception (IUC)—levonor- 1. Vital signs gestrel or copper-containing 2. General appearance and affect a. Can be placed immediately postdelivery 3. Breasts but has a 30% expulsion rate a. Condition of breasts and nipples b. If not placed within 48 hours postpartum, b. Status of milk production need to wait until 6 weeks postpartum 188 Chapter 6 Intrapartum and Postpartum

6. Lactational amenorrhea method • Constipation a. Full or nearly full breastfeeding 1. Increase fluids and fiber; stool softener b. Infant less than 6 months old 2. Encourage ambulation c. No menses 3. Laxatives d. Choose alternative method if woman and infant do not fit all three criteria • Hemorrhoids 7. Tubal ligation 1. Ice packs a. Permanent method of contraception 2. Topical anesthetics b. Most easily accomplished during hospital 3. Referral if thrombosed stay c. Generally need to obtain consent prior to Â Questions birth Select the best answer. • Diagnostic tests 1. Complete blood count 1. At 38 weeks’ gestation, Ms. Jones presents to a. Commonly performed first morning after your birth center complaining of a small amount birth of watery, clear-to-whitish vaginal discharge for b. Only profound anemia will change the past 8 hours. She has been having Braxton management Hicks contractions for a couple of days; the 2. Cord blood testing for blood type, Rh, and baby is moving on a regular basis, but now she Coombs just “doesn’t feel right.” What would you do in 3. Kleihauer-Betke screen if Rh negative your initial assessment related to her presenting symptoms? • Immunizations a. Obtain 20-minute fetal monitor strip to 1. Rubella vaccine may be given prior to dis- assure reactivity. charge if not immune to rubella b. Perform sterile speculum exam to R/O 2. RhoGAM prior to discharge if indicated rupture of membranes versus vaginal infection. Â Postpartal Discomforts c. Contact consulting physician regarding premature rupture of membranes protocol. • Involutional pain d. Send Ms. Jones home with reassurance and 1. Uncommon in primigravidas, increases in in- instructions to rest until better labor pattern tensity with each subsequent birth is established. 2. Increases with nursing 3. Nonpharmacologic relief 2. Mrs. Hogan, a 37-year-old G4 P0 at 35 weeks, a. Maintain empty bladder and bowels presents saying she is having bright red bleeding b. Prone position may relieve pain and clots for 2 hours since intercourse with her 4. Pharmacologic relief husband. She has saturated 2 pads in 2 hours. a. Acetaminophen, ibuprofen, codeine She is not having any pain. The most probable b. Ketorolac diagnosis is: a. Placenta previa • Diuresis—maintain fluids to prevent dehydration b. Cervical irritation from intercourse c. Placental abruption • Breast engorgement d. Normal bloody show 1. Initiate breastfeeding early and often 2. Supportive brassiere 3. Tocolysis of premature labor contractions is most 3. Warm compresses effectively achieved by: 4. If bottle feeding, tight brassiere, ice packs, a. NSAIDS analgesics, reassurance about time limitation, b. Beta sympathomimetics such as terbutaline iced cabbage leaves for comfort c. Intravenous fluids d. Oxytocics • Perineal pain 1. Evaluate by REEDA 4. Which client is most at risk for placental 2. Topical medications abruption? a. Witch hazel pads a. 19-year-old G2 P0010 in preterm labor at 35 b. Dibucaine, benzocaine weeks Questions 189

b. 28-year-old G1 pregnant with twins with a. Hyperbilirubinema spontaneous rupture of membranes at 37 b. IUGR weeks c. Hyperglycemia c. 28-year-old G3 P2002 with induced labor at d. Shoulder dystocia 41 weeks A client who is a G3 P2002 at 38 weeks pre- d. 41-year-old G1 pregnant who had low-lying sents with regular uterine contractions every placenta in first trimester 4–6 minutes for 60 seconds for the past 6 hours. 5. What is the major risk of multifetal gestation? Her vaginal exam is 1–2 cm/30%/–2, vertex with intact membranes. a. Eclampsia b. Gestational diabetes 11. At this time, the patient is in: c. Cephalopelvic disproportion d. Preterm birth a. Prodromal labor b. Latent labor 6. The cardinal movements of labor and birth are c. Active labor which of the following? d. Not in labor a. Flexion, descent, internal rotation, extension, 12. Your management plan at this time is: restitution, external rotation b. Descent, flexion, extension, internal rotation, a. Discharge home with instructions external rotation, restitution b. Ambulate for 2 hours and then reassess c. Descent, flexion, internal rotation, extension, c. Contact consulting physician for augmenta- restitution, external rotation tion of labor d. Descent, flexion, internal rotation, extension, d. Need additional information prior to formu- external rotation, restitution lating plan 7. The cardinal movement responsible for the birth Three hours later, you re-assess this client. Con- of the fetal head in the vertex presentation is: tractions are now every 4 minutes for 60 seconds. Her exam is 2 cm/50%/–2, vertex with intact a. Flexion membranes. The fetal heart rate is 150 with b. Restitution audible accelerations by Doppler. c. Extension d. External rotation 13. At this time your client is in: 8. The definition of postpartum hemorrhage is: a. Prolonged latent phase a. Blood loss in excess of 500 cc or more after b. Latent phase of labor the third stage of labor c. Active phase of labor b. Blood loss in excess of 750 cc during the d. Cannot make a determination based on this entire labor information c. Blood loss of more than 500 cc before a Six hours later the client has the same contrac- C-section tion pattern every 4 minutes for 60 seconds. Her d. Blood loss of 750 cc or more after the third exam is now 2–3 cm/100%/0, vertex with intact stage of labor membranes. The fetal heart rate remains in the 9. Which of the following statements concerning 140s to 150s with audible accelerations. The Apgar scores is correct? client is exhausted and is no longer coping well with the contractions and “just wants it over.” a. Scoring is especially useful in assessment of the preterm infant. 14. Your diagnosis at this time is: b. Scoring is less useful when the infant is postterm. a. Latent phase of labor c. A score of less than 7 at 1 minute correlates b. Prolonged latent phase of labor with increased neonatal morbidity. c. Arrested labor d. Five-minute scoring has a relationship to d. Protracted active phase of labor neonatal morbidity and mortality. 15. Your management plan at this time is: 10. Infants born to mothers with gestational dia- a. Discharge home with encouragement and betes are at increased risk for: instructions to return when the contractions become closer 190 Chapter 6 Intrapartum and Postpartum

b. Contact consulting physician regarding your 22. Intermittent auscultation of the fetal heart rate plan for oxytocin augmentation during labor is: c. Encourage her to continue with her original a. Inferior to continuous electronic fetal plan for an unmedicated childbirth monitoring d. Offer medication of morphine 10 mg IM b. Acceptable only for out-of-hospital birth so she can get some sleep and potentially c. Acceptable for the fetal monitoring of correct this dysfunctional labor pattern certain patients 16. C. S. presents to your office stating she is preg- d. Correlated to lower Apgar scores than babies nant and wants to know her due date. The first born after continuous fetal monitoring day of her last period was February 4. Her due 23. Your patient states that she does not want an date by menstrual dating (Naegele’s rule) would episiotomy no matter what happens. Your man- be: agement of this situation would be: a. November 11 a. Discuss the indications for episiotomy and b. October 28 reinforce that you would obtain consent c. May 11 prior to performing the procedure, if d. November 4 necessary 17. The denominator of breech presentation is the: b. Teach her perineal massage antenatally and hope that she will not need an episiotomy a. Symphysis pubis c. Explain to her that skilled midwives never b. Sacrum perform episiotomies c. Feet d. Explain that since this is her first baby, that d. Shoulders she will probably need an episiotomy to 18. Your client is in active labor making appro- prevent serious laceration priate progress thus far. Currently her exam is 24. A client presents while you are covering Labor 6 cm/100%/–2, vertex with intact membranes. and Delivery. She is a 33-year-old G3 P2002 During your exam, you notice the position of the at term in labor with ruptured membranes. vertex is LOT and sagittal suture of the fetus is Your exam reveals 5 cm/90% effaced/0 station closer to the maternal sacrum. Your diagnosis at but you are unable to palpate fontanels or this time is: sutures. You suspect that you feel the orbital a. Deep transverse pelvic arrest ridge in the anteroposterior diameter and the b. Anterior asynclitism chin at 3 o’clock. If this is the case, what is the c. Failure to descend presentation? d. Posterior asynclitism a. ROT 19. Your management plan for this patient would b. LMT be: c. RMT d. ROA a. Artificial rupture of membranes b. Epidural anesthesia 25. Three hours later, the same client is completely c. Pitocin augmentation dilated/100% effaced/0 station. Your exam now d. Encourage movement and position change reveals that the presentation is MA. What would your next step be? 20. On the monitor strip of the same client, you notice the fetal heart rate has intermittently a. Prepare client for urgent C-section been 100–110 bpm for 20–30 seconds at a time b. Manually attempt to flex the fetal head for 10–15 minutes with good return to baseline. c. Encourage patient to push as effectively as You would document this as: possible d. Allow patient to only push in the hands and a. Variable decelerations knees position to allow the fetal head to b. Late decelerations rotate c. Fetal bradycardia d. Cannot determine from this information 26. During an assisted breech birth, if a nuchal arm is encountered, what should you do? 21. The largest diameter of the fetal head is the: a. Exert steady downward traction on the a. Verticomental entire fetus b. Submentobregmatic b. Slowly rotate the infant 180° to attempt to c. Occipitofrontal dislodge the arm d. Suboccipitobregmatic Questions 191

c. Raise the baby in a warm towel above the 31. At 10:00 p.m., she requests something for pain plane of the vagina because she states the pain is intolerable now d. Sweep the arm down by hooking the elbow and she is feeling increased pelvic pressure. What and pulling the arm down would not be indicated for pain relief at this time? 27. The most common cause of postpartum hemorrhage is: a. Epidural anesthesia b. Intravenous narcotics a. Sulcus tears c. Pudendal anesthesia b. Episiotomy extensions to third- and fourth- d. Paracervical block degree lacerations c. Uterine atony 32. At 10:50 p.m., you notice on the fetal monitor d. Cervical lacerations strip early decelerations that occur with every contraction. The baseline heart rate is in the 140s 28. The process of involution takes place over which with average variability. What do you suspect the of the following time frames? cause of these decelerations is? a. The first 6 weeks postpartum a. Maternal hypotension b. The first 24 hours postpartum b. Head compression c. The first 2 weeks postpartum c. Uteroplacental insufficiency d. The first year postpartum d. Fetal distress related to the meconium fluid The following is the clinical picture of your client. 33. The benefit of placing an internal scalp electrode She is a G1 P0 at 39 weeks with an uncompli- on a fetus in labor is: cated pregnancy. Her labor started at 4:00 a.m. with regular contractions. She was admitted at a. The ability to assess short-term variability 8:00 a.m. when her exam was 2–3 cm/100%/–2 b. The ability to detect decelerations station, vertex, membranes intact. c. It keeps the client in bed d. The ability to assess long-term variability At 12:00 p.m. her exam was 3–4 cm/100%/–2, 34. If you are performing a fetal scalp sample to intact. assess fetal pH, what level would cause you to immediately prepare the patient for a C-section? At 4:00 p.m., her exam was 4 cm/100%/–2, intact. a. 7.41 At 7:30 p.m. her exam was 5–6 cm/100%/–1, b. 7.21 intact. c. 7.20 d. 7.16 At 8:15 p.m., she ruptured membranes for light 35. What is the most common position for birth? meconium stained fluid. a. ROA At 10:00 p.m., her exam was 8 cm/100%/0 b. LOA station. c. ROP d. LOP 29. Based on the information provided above, at 36. The long arc rotation is most commonly per- 12:00 p.m. what was the most appropriate diag- formed by babies beginning labor in which nosis related to your client’s labor progress? presentation? a. Latent phase a. LOP b. Protracted latent phase b. LSA c. Unable to make determination with this c. ROA information d. LOA d. Active labor 37. In the second stage of labor, how frequently 30. At 7:30 p.m., what was the most appropriate should the BP of low-risk women be checked? diagnosis? a. Every 30 minutes a. Unable to make determination based on the b. Every 5 minutes information provided c. Every 60 minutes b. Protracted active phase of labor d. Every 15 minutes c. Arrest of labor in the active phase d. Active phase of labor 192 Chapter 6 Intrapartum and Postpartum

38. When is the most appropriate time to administer 45. During uterine contractions, intervillous blood pudendal anesthesia for perineal pain relief in flow to the placenta the multiparous client? a. Increases a. For the repair of any laceration or b. Decreases episiotomy c. Remains unchanged b. When the head distends the perineum and d. Has not been studied in humans client complains of the “ring of fire” 46. Average long-term variability of the fetal heart c. When the vertex is at +2 rate is a change of how many beats per minute d. At approximately 8–9 cm dilated from the baseline? 39. What is the largest group of muscles in the pelvic a. Less than 2 musculature? b. 2–6 a. Levator ani c. 6–10 b. Pubococcygeus d. 10–15 c. Bulbocavernosus 47. Which of the following would not cause an alter- d. Sphincter ani ation in the LTV of the fetal heart rate? 40. In a second-degree laceration, which structure is a. Medications not involved? b. Congenital cardiac anomalies of the fetus a. Vaginal mucosa c. Placenta previa b. Deep transverse perineal muscles d. Fetal activity patterns c. Rectal sphincter 48. Your client, who you are comanaging with your d. Hymenal ring consulting physician, is 33 weeks and 4 days 41. The Ritgen maneuver is used to: pregnant admitted with premature labor with a cervical exam of 2–3cm/80%/–1, vertex, intact. a. Slow down the descent of the fetal head She is currently on MgSO at 3.0 g/hour with during birth 4 occasional contractions. During rounds, she com- b. To control expulsion of the fetal head at the plains of feeling flushed and hot, lethargic and time of birth sort of short of breath, which usually gets better c. To avoid lacerations or the need for an when she changes position. Which response episiotomy would be best to address her complaints? d. To assist in the delivery of the fetal head

during extension a. “The MgSO4 commonly makes you feel like this, but hopefully they will start weaning 42. What complication may be encountered if a pla- the medication today.” centa is delivered by the Duncan mechanism? b. “Well, since you are almost 34 weeks, I could a. Increased perineal lacerations ask the doctor if we can discontinue the b. Increased bleeding medication now.” c. Increased hemorrhoids due to extra maternal c. “I don’t think that you should be having pushing effort shortness of breath like you are; I am going d. Uterine inversion to have the physician see you and order a chest radiograph.” 43. Which of the following would not be included in d. “Being a little uncomfortable is so much the differential diagnosis of premature labor? better than giving birth to a 33-week-old a. Urinary tract infection infant.” b. Appendicitis 49. Which of the following conditions would not c. Renal colic necessitate continuous fetal monitoring? d. Heartburn a. Labor at 41 weeks and 1 day 44. The fetal heart rate variability is predominantly b. Thick meconium stained fluid controlled by: c. Nonreactive NST who is now in labor a. The parasympathetic nervous system d. IV narcotics b. The baroreceptors 50. Mothers in premature labor are given glucocorti- c. The chemorectors costeroids to: d. The sympathetic nervous system a. Help stop the uterine contractions b. Prevent infections especially chorioamnionitis Questions 193

c. Speed the maturation of the fetal respira- c. The biparietal diameter is at the level of the tory system, including the production of pelvic inlet surfactant d. The head is on the perineum d. Prevent muscle wasting commonly seen in 56. When an IUPC is used for the assessment of bedrest patients uterine contractions, the adequacy is quantified 51. Kelly Jones, a G3 P2002 at 37 weeks and 1 day, in: presents to Labor and Delivery with regular a. Millimeters of mercury contractions every 2–3 minutes for 5 hours. Your b. Mild, moderate, and strong vaginal exam reveals 6 cm/100%/–2, LSA with c. Montevideo units ruptured membranes positive for light meco- d. Centimeters nium. What is your next step: 57. By internal monitoring of uterine contractions, a. Admit for expectant management which of the following must be achieved in the b. Discuss with Kelly her birth plan course of 10 minutes in order to be considered c. Await a reactive tracing before making a adequate contractile strength to dilate the management plan cervix? d. Notify your consulting physician and prepare for a C-section a. 80–100 Montevideo units b. 80–100 mm Hg 52. A complete breech presentation is described as: c. 180–200 Montevideo units a. One or two feet are the presenting part d. 180–200 mm Hg b. Legs and thighs are flexed with buttocks 58. Which of the following would represent a con- presenting traindication for the use of an IUPC? c. The baby is flexed at the hips d. The knees are the presenting part a. Maternal birth plan b. Breech presentation 53. Your client, who is 41 weeks and 5 days preg- c. HIV nant, presents for postdates testing including a d. Lack of labor progress nonstress test. When you assess the tracing after 20 minutes, the FHR is 140-145/min, there are no 59. In the first stage of labor, for low-risk laboring decelerations, the LTV is average but the tracing women, the interval for intermittent fetal heart does not meet criteria for reactivity. What would rate auscultation is: you do? a. 15 minutes a. Admit the client and induce labor b. 20 minutes b. Begin a contraction stress test c. 30 minutes c. Use the vibroacoustic stimulator d. 60 minutes d. Continue nonstress test for another 20 60. All of the following are risk factors for preterm minutes labor except: 54. The same client as above is now in labor, at a. Age 4 cm/100%/+1, vertex, and she is having contrac- b. Smoking tions every 3–5 minutes for 50–70 sec, which are c. Race moderate to palpation. The FHR baseline is still d. Sex of fetus in the 140s, but she is having variable decelerations to the 110s with good return to baseline 61. Shelley Blank is seen in Labor and Delivery at and average variability. What action would be 33 weeks and 1 day complaining of menstrual- contraindicated at this time? type cramping for the past 3 hours. She denies bleeding or ruptured membranes. The fetus is a. Allowing the patient to get into the Jacuzzi active. The EFM reveals occasional uterine con- b. Beginning oxytocin augmentation tractions approximately every 8–12 minutes. The c. Inserting an intravenous catheter FHR is 135–140/min. Which of the following tests d. Expectant management would be most important in formulating your 55. The definition of engagement is: management plan? a. The fetal head reaches the pelvic floor a. Complete blood count b. The head descends to the level of the ischial b. Cervical culture spines c. Urine culture d. Ultrasound 194 Chapter 6 Intrapartum and Postpartum

62. What would be the next step in your manage- a. Prescribe an SSRI because adolescents are ment plan? prone to postpartum depression b. Encourage her to focus on her baby’s needs a. Expectant management until the lab results as her first priority now are back c. Explain that it is normal to have a combina- b. Tocolysis tion of sadness and euphoria so close to the c. Pain management time of the birth d. Additional information is necessary to for- d. Conduct a screening test for possible post- mulate the management plan partum depression 63. Which of the following represents a risk factor 69. During postpartum rounds, your multiparous for shoulder dystocia? client is very pleased with her birth and is clearly a. Advanced maternal age bonding with her new baby girl. She is suc- b. Epidural anesthesia cessfully nursing her baby every 3 hours for 5 c. Polyhydramnios minutes. She is asking about early discharge and d. Maternal obesity wants to go home as soon as possible. Her only complaint is that her left leg is sore because of 64. Which of the following elective vaginal births is her need to deliver in stirrups. What would be no longer recommended? the most important piece of your assessment? a. Brow presentation a. Availability of assistance at home with her b. Face presentation two other children to assure her rest c. Breech presentation b. Breast exam and assessment to check for d. Vertex presentation milk production to ensure adequacy of 65. During the birth of twins, which represents a feeding prior to discharge maneuver that should not be performed? c. Dietary recall to insure adequate kcal and fluids to produce adequate human milk a. Artificial rupture of membranes d. Examination of the lower legs to be sure b. Clamping and cutting of a nuchal cord that the muscle strain that she is complaining c. McRobert’s maneuver about is simply related to positioning d. Breech delivery of the second twin 70. The same client would like to resume birth 66. Which of the following represents a risk factor control prior to discharge. Which method would for retained placenta? be most appropriate for this client? a. Preterm delivery a. DMPA b. Multiple gestation b. IUD c. Multiparity c. Combination birth control pills d. Postterm pregnancy d. Diaphragm with spermicidal cream 67. While repairing a first-degree laceration, you 71. During the second stage of labor, for the low-risk notice a continual “trickle” of bright red blood client, the fetal heart rate should be monitored: from the vagina. As you continue your repair the bleeding becomes more brisk. What would be a. Every 5 minutes the next step after fundal massage in your man- b. Every 15 minutes agement plan? c. Every 30 minutes d. Continuously a. Bimanual compression b. Adding 20 additional units of oxytocin in the 72. A sudden bradycardia seen in the second stage IV of labor after an uneventful labor course and c. Discussion with the consulting physician previously normal fetal heart tracing is com- regarding management plan monly caused by: d. Methylergonovine IM if BP is normotensive a. A vagal response in the fetus related to 68. Thirty six hours after birth, you find Megan, a descent 16-year-old, crying quietly with the baby in her b. Fetal hypoxia related to length of labor room as you perform a.m. rounds. What would c. Cord prolapse be the most helpful response? d. Uteroplacental insufficiency Answers 195

73. Which of the following FHR tracings are indica- Â Answers tive of nonreassuring fetal status? â 1. b 40. c a. A prolonged deceleration with recovery to baseline with average short-term variability â 2. a 41. d b. Variable decelerations that become more â 3. b 42. b pronounced during the second stage but â 4. b 43. d with normal FHR between pushing efforts â 5. d 44. a c. A rising baseline and absence of short-term â 6. c 45. b variability â 7. c 46. c d. Late decelerations with return to baseline â 8. a 47. c and average long-term variability between â 9. d 48. c decelerations 10. d 49. a 74. The risk factor that is most predictive of a 11. b 50. c preterm birth during a current pregnancy is: 12. b 51. d a. Uterine contractions 13. b 52. b b. Prior preterm labor 14. b 53. d c. Prior preterm birth 15. d 54. a d. Preeclampsia 16. a 55. b 75. The pain of the second stage of labor is caused 17. b 56. c by: 18. b 57. c a. Uterine muscle hypoxia with lactic acid build- 19. d 58. c up and distention of the musculature of the 20. a 59. c pelvic floor 21. d 60. d b. Cervical and lower uterine segment 22. c 61. c stretching and traction on the ovaries, fallo- 23. a 62. d pian tubes, and pelvic ligaments 24. b 63. d c. Pressure on the bony pelvis, urethra, bladder, 25. c 64. c and rectum 26. d 65. b d. Fundal uterine displacement and extension of the fetal lie 27. c 66. a 28. a 67. d 76. Hemodynamic changes during the initial post- 29. a 68. c partum period include: 30. b 69. d a. Elevated cardiac output for up to 48 hours 31. b 70. a after the birth 32. b 71. b b. Decreased WBC during the first 72 hours 33. a 72. a postpartum 34. d 73. c c. Elevated blood pressure for 48 hours after 35. b 74. c the birth d. Decreased urine output for the first 24 hours 36. a 75. c 37. d 76. a 77. In the initial newborn period, a 10-minute Apgar 38. d 77. c score is performed: 39. a 78. a a. Routinely b. If the 1-minute Apgar score was less than 7 c. If the 5-minute Apgar score was less than 7 d. If the combined Apgar score at 1 and five minutes is less than 16 78. The bluish discoloration of the baby’s hands and feet within the first 24–48 hours after birth is: a. Acrocyanosis b. Circumoral cyanosis c. Central cyanosis d. Mongolian spots 196 Chapter 6 Intrapartum and Postpartum

Â Bibliography Cunningham, F. G. et al. (Eds.). (2001). Williams Obstet- rics (21st ed.). New York: McGraw-Hill. Albers, L. (2007). The evidence for physiologic man- Enkin, M., Krurse, M. J. N. C., Nelison, J., Crowther, agement of the active phase of the first stage of la- C. (2000). A guide to effective care in pregnancy and bor. Journal of Midwifery and Women’s Health, 52(3), childbirth (3rd ed.). Oxford, UK: Oxford University 207–215. Press. American College of Obstetricians and Gynecologists Gabbe, S., Simpson, J., Niebyl, J., Galen, H. et al. (2007). (ACOG). (2006). The Apgar score. Committee Opinion Obstetrics: Normal and problem pregnancies (5th ed.). No. 333. Washington, DC: Author. Philadelphia, PA: Mosby Elsevier. American College of Obstetricians and Gynecologists Gibbs, R., Karlan, B., Haney, A., & Nygaard, I. (2008). (ACOG). (2006). Episiotomy. Practice Bulletin No. 71. Danforth’s obstetrics and gynecology (10th ed.). Phila- Washington, DC: Author. delphia, PA: Lippincott, Williams, and Wilkins. American College of Obstetricians and Gynecologists Hatcher, R. A. et al. (2007). Contraceptive technology (ACOG). (2003). Management of preterm labor. Prac- (19th ed.). New York: Ardent Media. tice Bulletin No. 43. Washington, DC: Author. Lowdermilk, D., & Perry, S. (2007). Maternity and wom- American College of Obstetricians and Gynecologists en’s health (9th ed.). Philadelphia, PA: Mosby Elsevier. (ACOG). (2002). Shoulder dystocia. Practice Bulletin Riordan, J., & Auerbach, K. (2010). Breastfeeding and No 40. Washington, DC: Author. human lactation (4th ed.). Sudbury, MA: Jones and Blackburn, S. T. (2002). Maternal, fetal and neonatal Bartlett. physiology: A clinical perspective (2nd ed.). Philadel- Seidel, H. M., Rosenstein, B. J., & Pathal, A. (2001). Pri- phia, PA: W. B. Saunders. mary care of the newborn (3rd ed.). St. Louis: Mosby, Butarro, T. M., Trybulski, J., Bailey, P. P., & Sandberg- Inc. Cook, J. (2008). Primary care: A collaborative practice Tharpe, N., & Farley, C. (2009). Clinical practice guide- (3rd ed.). Philadelphia, PA: Mosby Elsevier. lines for midwifery and women’s health (3rd ed.). Sud- Coad, J. (2001). Anatomy and physiology for midwives. bury, MA: Jones and Bartlett. Edinburgh, UK: Mosby, Inc. Varney, H., Kreibs, J., & Gegor, C. (2004). Varney’s mid- Creasy, R., & Resnik, R. (2009). Maternal fetal medicine: wifery (4th ed.). Sudbury, MA: Jones and Bartlett. Principles and practice (6th ed.). Philadelphia, PA: W. B. Saunders. 7 Gynecological Disorders

Penelope Morrison Bosarge

¶ MENSTRUAL AND ENDOCRINE (3) Fluid retention DISORDERS (4) Swelling (5) Abdominal bloating Premenstrual Syndrome (PMS) (6) Nausea/vomiting (7) Alterations in appetite UÊ ivÌpÌ iÊVÞVVÊVVÕÀÀiVi]ÊÊÕÌi>Ê« >Ãi]Ê (8) Food cravings of a group of distressing physical and psychologi- (9) Lethargy/fatigue cal symptoms, which begin at or after ovulation (10) Exacerbations of preexisting condi- and resolve shortly after onset of menses and tions, such as asthma that disrupt normal activities and interpersonal b. Psychological relationships (1) Irritability (2) Depression UÊ Ì}ÞÉV`iVi (3) Anxiety 1. Unknown etiology; multifactorial and mul- (4) Sleep alterations tiorgan disorder; suggested causes include (5) Inability to concentrate metabolic and endocrine disorders, alterations (6) Anger in estrogen or progesterone levels, withdrawal (7) Violent behavior of endogenous endorphins, fluid imbalance, (8) Crying vitamin and mineral deficiencies, and altered (9) Confusion carbohydrate metabolism (10) Changes in libido 2. Prevalence may be greater than 50% with most women not requiring treatment; severe cases UÊ * ÞÃV>Êv`}ÃpÊÃ«iVvVÊ« ÞÃV>Êv`}Ã occur in 3–10% of women with PMS UÊ vviÀiÌ>Ê`>}ÃÃ UÊ -}ÃÊ>`ÊÃÞ«ÌÃ 1. A diagnosis of exclusion; all others must be 1. Symptoms recur cyclically in the luteal phase ruled out with symptom-free period in the follicular 2. Depression and/or anxiety phase 3. Bipolar affective disorder 2. Range from mild to severe, resulting in inter- 4. Alcohol or substance abuse ference with normal activities and personal 5. Personality disorders relationships 6. Chronic fatigue syndrome a. Physical 7. Fibromyalgia (1) Headache 8. Diabetes (2) Breast changes 9. Brain tumor

197 198 Chapter 7 Gynecological Disorders

10. Thyroid disease d. Combined oral contraceptives may 11. Hyperprolactinemia be helpful in decreasing physical 12. Perimenopause symptoms—especially type containing drospirenone (spironolactone derivative) • Diagnostic tests/findings e. Danazol in low doses for luteal phase only 1. Documentation of symptoms in a diary fash- may relieve breast pain ion for 2 to 3 months, to evaluate for symptom f. Selective serotonin reuptake inhibitors consistency with ovulation and menses; retro- (SSRI) or selective serotonin and norepi- spective recall inaccurate nephrine reuptake inhibitors (SNRI) anti- 2. Individualized testing, based upon symptoms, depressant medications have been shown may include glucose tolerance test and thyroid to alleviate severe PMS; may choose to profile; hormone levels of little value take only in luteal phase each month g. Gonadotropin-releasing hormone ago- • Management/Treatment nists (GnRH) to inhibit cyclic gonado- 1. Nonmedical management tropin release; long-term therapy may a. No standard treatment; goal is to isolate predispose to heart disease or osteopo- symptom groups from history and diary rosis—limit use to 4 to 6 months unless and treat symptomatically combined with combination hormonal b. Options for treatment therapy (1) Self-help strategies recommended as first line therapy; help client under- • Premenstrual dysphoric disorder (PMDD) stand the possible causes of symp- 1. At least 5 PMS-type symptoms severe enough toms, reassuring her that no serious to markedly disrupt normal functioning in health threats exist, and there are no most if not all menstrual cycles quick cures; patience and team effort 2. Occurs in luteal phase and resolves within 1 are key week after menses (2) Suggested dietary revisions are restric- 3. Must include at least one of these symptoms— tion of salt to 3 g, refined sugar to 5 markedly depressed mood, marked anxiety, tsp, and red meat intake to 3 oz or less marked affective lability, persistent and per day; limit caffeine, alcohol, and fat marked anger intake; hypoglycemic diet may be of 4. Prevalence, 3–10% of reproductive age women value 5. Treatment—SSRI/SNRI, combination oral (3) Vitamin and mineral supplementation contraceptives containing drospirenone if as a treatment is poorly documented; also desires contraception, other hormonal magnesium or magnesium-rich foods, interventions pyridoxine (no more than 100 to 300 mg a day), vitamin A and E may re- Dysmenorrhea lieve some breast symptoms and are • Definition often suggested; large doses of supple- 1. Painful menstruation—a sensation of cramp- ments may be toxic ing in lower abdomen during or just before (4) Calcium supplementation marginally menses; most severe on first day, usually lasts superior to placebo in randomized 2 days, may radiate to back and thighs placebo-controlled trial 2. Primary—dysmenorrhea occurs unassociated (5) Aerobic exercise 20 to 30 minutes at with underlying pelvic pathology, rarely begins least 4 times a week after age 20, associated with ovulatory cycles, (6) Avoidance of known physical or emo- is stimulated by prostaglandin release tional triggers 3. Secondary—an underlying pelvic pathologic (7) Self-help, support groups, psychologi- condition thought to be the cause cal counseling valuable in treatment 4. May occur at any age in menstruating women 2. Medical management a. Selection of medications based on type • Etiology/Incidence and intensity of symptoms 1. Primary—seen in 50–75% of all menstruating b. Spironolactone during luteal phase to re- women with 10–20% severe; prostaglandins duce swelling and bloating stimulate contractile response on smooth c. Mefenamic acid (antiprostaglandin) men- muscles strually and premenstrually may reduce 2. Secondary—onset may be many years after fluid retention and menstrual pain menarche; most often in women older than age 20; organic disease is related Menstrual and Endocrine Disorders 199

• Signs and symptoms (NSAIDs) are treatment of choice; best 1. Primary if begun at onset of menses, continuing a. Pain begins shortly before the onset of for 48 to 72 hours; choices shown to be menses and usually lasts no longer than 2 effective are mefenamic acid, naproxyn days sodium, ibuprofen, and indomethacin b. Described as colicky, crampy, and spas- b. Oral contraceptive pills (OCPs) are good modic pain in the lower abdomen, some- choice if contraception is needed; act by times radiating to lower back and thighs reducing prostaglandins and menstrual c. May interfere with work or school flow; may consider extended or continu- (15–29%) ous dosing regimens 2. Secondary c. NSAIDs and OCPs may be used in a. Pain may begin at any time during the combination cycle; may notice change in duration and d. Other hormonal contraceptives may amount of menstrual flow also relieve symptoms by decreasing or b. Unlikely to be relieved by over-the- eliminating menstrual bleeding—depo counter measures medroxyprogesterone acetate (DMPA), c. Symptoms often persist longer then pri- levonorgestrel-releasing intrauterine sys- mary; related to organic pathology tem (LNG-IUS) e. Self-help measures include exercise, warm • Physical findings heat, relaxation exercises 1. Primary—characterized by no abnormalities 2. Secondary treatment consistent with found on examination pathology 2. Secondary—has findings consistent with pathologic condition Amenorrhea

• Differential diagnosis • Definition 1. Imperforate hymen 1. Absence of menses during reproductive years 2. Endometriosis 2. Primary—no menstruation previously; no 3. Cervical stenosis menstruation by age 14 in absence of devel- 4. Uterine abnormalities opment of secondary sex characteristics; no 5. Pelvic infection menstruation by age 16 regardless of second- 6. Ovarian cysts ary sex characteristics 7. Pelvic congestion 3. Secondary—absence of menses in a previously 8. Chronic pelvic pain menstruating woman; no menses for 6 months 9. Adhesions in a woman who usually has normal periods or 10. Sexually transmitted infections for a length of time equivalent to three cycles 11. Urinary tract infections 4. A symptom, not a diagnosis

• Diagnostic tests/findings • Etiology/Incidence 1. Primary—no specific tests are ordered 1. Vaginal agenesis 2. Secondary 2. Imperforate hymen a. Analyze pain description to help deter- 3. Atrophy mine etiology 4. Infection b. Tests according to history and physical 5. Irradiation and surgery resulting in destruc- examination findings may include: tion of endometrium (Asherman’s syndrome) (1) Vaginal ultrasound and hysterosalpin- 6. Stress gogram to evaluate pelvic structures 7. Genetic anomalies (2) Laparoscopy to evaluate endometrial 8. Endocrine imbalances cavity 9. Weight abnormalities (3) Cultures, smears to evaluate 10. Medications infections 11. Chronic illness (4) Lower gastrointestinal (GI) evaluation 12. Excessive exercise 13. Incidence is approximately 5% in women who • Management/Treatment are not pregnant, lactating, or menopausal 1. Primary a. Prostaglandin synthetase inhibitors, • Signs and symptoms—absence of menses at the nonsteroidal anti-inflammatory drugs expected time 200 Chapter 7 Gynecological Disorders

• Physical findings • Management/Treatment 1. Abnormal vital signs may indicate chronic 1. Primary amenorrhea, refer to endocrinologist illness 2. Treat thyroid abnormalities or refer 2. Abnormal visual fields, enlarged or nodular 3. If prolactin and TSH are normal and bleeding thyroid, or breast discharge may indicate en- occurs after progestin challenge, initiate treat- docrine disorder ment for anovulation based on age, contracep- 3. Enlarged uterus may indicate pregnancy tive needs, and lifestyle 4. Delay in Tanner stage progression may in- 4. Treatment may include combination hor- dicate altered development of secondary monal contraceptives or cyclic progestins sex characteristics, while hirsutism, clitoral 5. Referral for ovulation induction if desires enlargement, and acne may mean androgen pregnancy excess 5. Normal estrogen production manifested by Oligomenorrhea pink, moist, rugated vaginal mucosa as seen on speculum examination • Definition—infrequent uterine bleeding in which interval between bleeding episodes may vary from • Differential diagnosis 35 days to 6 months 1. Pregnancy 2. Menopause • Etiology/Incidence 3. Anorexia nervosa 1. Occurs frequently in perimenopause 4. Disorders of ovary, anterior pituitary and/or 2. Ovarian-pituitary-hypothalamus hypothalamus such as pituitary tumors, abnormalities gonadotropin deficiency, polycystic ovar- 3. Endocrine disorders such as thyroid or adrenal ian syndrome, ovarian failure, Sheehan’s problems syndrome 4. Systemic causes such as chronic illness, weight 5. Anatomical disorders such as genetic or con- loss or gain, extreme stress, excessive exercise genital anomalies (Turner’s syndrome, andro- 5. Drug use or abuse gen insensitivity syndrome) and destructive changes such as Asherman’s syndrome • Signs and symptoms 6. Chronic illness—hypothyroidism, hyperthy- 1. May alternate with episodes of amenorrhea or roidism, tuberculosis, alcohol abuse, type 1 heavy vaginal bleeding diabetes mellitus, disorders of adrenal glands, 2. May present as normal menstrual pattern dur- obesity ing first year of menstruation or for several 7. Medication effects—hormonal contraceptives, years prior to menopause psychotrophic drugs (phenothiazines), reser- pine, dilantin • Differential diagnosis 1. Pregnancy • Diagnostic tests/findings 2. Menopause 1. Pregnancy test 3. Thyroid disorder 2. Serum prolactin level 4. Disturbance with hypothalamic-pituitary- 3. Thyroid stimulating hormone (TSH) ovarian axis 4. If above tests are normal, may evaluate availability of estrogen with progestin challenge • Physical findings—consistent with pathology test found in Differential diagnosis section a. Progesterone each day for 5 to 10 days— wait for bleeding, which should occur • Diagnostic tests/findings within 7 days; will indicate adequate es- 1. Pregnancy test (beta hCG) to rule out trogen production and stimulation as well pregnancy as no problem with outflow tract 2. Tests to evaluate function of thyroid, ovaries, b. Should withdrawal bleeding not occur, pituitary or hypothalamus, e.g., TSH, prolactin prime endometrium with estrogen to level, gonadotropin levels ensure proliferation; estrogen orally for 21 days, add progesterone orally for last 5 • Management/Treatment days 1. If pregnant, discuss options c. Repeat challenge test; if bleeding occurs, 2. Treat underlying cause, e.g., stress, weight— order specific test to determine if problem possibly refer to an endocrinologist is in pituitary or ovary, or refer Menstrual and Endocrine Disorders 201

3. Prevent unopposed estrogen complications by 2. Ovaries may not always be palpable—50% will giving progesterone therapy—medroxyproges- have enlarged ovaries terone acetate 10 days of each month or com- 3. Virilization—hirsutism, increased muscle bination hormonal contraceptives mass, frontal balding, enlargement of clitoris, deepening of voice, and decreased breast size Polycystic Ovarian Syndrome (PCOS) 4. Abdominal obesity 5. Acne • Definition—a symptom complex associated with 6. Acanthosis nigricans and skin tags usually in oligo-ovulation or anovulation and clinical or bio- neck area chemical signs of hyperandrogenism • Diagnostic tests/findings • Etiology/Incidence 1. Serum beta hCG to rule out pregnancy 1. Etiology is unclear 2. Progesterone challenge test resulting in 2. Primary hormonal abnormality is increased bleeding luteinizing hormone (LH) with low or normal 3. LH elevated; FSH normal or low (3:1 ratio) follicle stimulating hormone (FSH)—ratio is 4. Prolactin mildly elevated or normal more than 3:1; results in dysregulation of an- 5. Serum total testosterone and free testoster- drogen secretion with increased testosterone one—mild to moderate elevation, which may and androstenedione production mean androgen excess 3. Another cause may be hyperinsulinemia as- 6. Thyroid function tests—high or low TSH sociated with insulin resistance; insulin has 7. Dehydroepiandrosterone sulfate (DHEAS)— effects at both the ovarian stroma and the fol- normal to elevated licle; can have a significant impact on promot- 8. Endometrial biopsy—to rule out hyperplasia ing or disrupting follicles 9. Basal body temperature reading to indicate 4. Approximately 25% of normal women will evidence of ovulation—use to schedule endo- demonstrate ultrasonographic evidence typi- metrial biopsy cal of polycystic ovaries 10. Assess ovaries with ultrasonography 5. Prevalence in reproductive women is approxi- 11. Laparoscopy to determine and manage fertility mately 6–7% (most common endocrine disor- 12. Glucose and lipid levels der in this population) 6. Women are at risk for future development of • Management/Treatment endometrial cancer, diabetes mellitus, and 1. Initial goal is to lower androgen levels heart disease; obesity increases risk of meta- and decrease risk for long-term effects of bolic complications hyperandrogenism 2. May be determined by desire for pregnancy • Signs and symptoms and symptom patterns 1. History of irregular menses (amenorrhea or 3. If pregnancy desired, refer to reproductive oligomenorrhea) endocrinologist 2. Gradual onset of hirsutism around puberty or 4. If pregnancy not desired, direct therapy on in early 20s prevention of endometrial hyperplasia and 3. Signs of androgen excess—acne, hirsutism, pregnancy deep voice, male pattern baldness a. Endometrial biopsy may be indicated 4. May have acanthosis nigricans b. Medroxyprogesterone acetate for 10 days 5. Obesity may be present (40%) of month induces withdrawal bleeding 6. Infertility c. Low dose combined OCP with low andro- genicity is an option for women under 35 • Differential diagnosis and those older than 35 who do not smoke 1. Dysfunctional uterine bleeding 5. Be observant for signs of diabetes, heart dis- 2. Obesity ease, breast cancer, and endometrial cancer 3. Hyperprolactinemia 6. Weight loss if obese 4. Thyroid dysfunction 7. Insulin sensitizing agents—metformin 5. Cushing’s disease 8. Excess hair removal—mechanical or eflorni- 6. Adrenal or ovarian tumors thine HCl topical cream for facial hair

• Physical findings 1. Physical findings may be normal 202 Chapter 7 Gynecological Disorders

Endometriosis 5. Lesions may be visible on laparoscopy or laparotomy • Definition—the presence of endometrial stroma 6. Cervical motion tenderness associated with and glands outside uterus menses

• Etiology/Incidence • Differential diagnosis 1. Etiology is not clearly understood 1. Chronic pelvic inflammatory infection 2. Possible causes include 2. Acute salpingitis a. Retrograde menstruation (Sampsom’s 3. Adenomyosis theory) 4. Ectopic pregnancy b. Immunologic factors 5. Benign or malignant ovarian neoplasm c. Genetics d. Hormonal factors • Diagnostic tests/findings 3. Found in 5–15% of surgeries performed on 1. Direct visualization with laparoscopy or lapa- reproductive age women and up to 30% of in- rotomy may reveal classic implants; classified fertile women as Stage I-minimal, Stage II-mild, Stage III- 4. Typical patient is 20 to 30 years old, Caucasian, moderate, Stage IV-severe nulliparous (60–70%) 2. CT and MRI provide only presumptive 5. Occurs in all races evidence 6. 7–10% of premenopausal women are affected; 3. CA-125 levels correlate with degree of disease most common cause of chronic pelvic pain and response to therapy, cannot be used for 7. Endometriosis has been found in areas other diagnosis due to low sensitivity and specificity than pelvis, such as lungs, nose and spinal column; most common sites are cul-de- • Management/Treatment sac, ovary, posterior uterus and uterosacral 1. No medical management provides universal ligaments cure; goal is to relieve pain, restore fertility and 8. Majority have a positive family history prevent progression 2. Medical management includes • Signs and symptoms a. Analgesics (NSAID first choice) 1. Wide range of clinical symptoms; severity does b. GnRH agonists and danazol induce regres- not correlate with extent of disease sion of endometrial implants 2. Most common complaints c. Progestins—Sub Q 104 DMPA is FDA a. Dysmenorrhea approved for treatment; IM DMPA also b. Infertility effective c. Premenstrual spotting d. Continuous use of combined oral contra- d. Menorrhagia ceptive pills produces atrophy of implants e. Pelvic pain and acyclic hormone environment f. Dyspareunia e. Laser surgery may be employed 3. Symptoms seen less often include: f. Hysterectomy, bilateral salpingoophorec- a. Low back pain tomy is curative b. Diarrhea g. May combine surgery and medication c. Dysuria 3. Key points d. Hematuria a. May need long term emotional support e. Dyschezia due to pain and infertility f. Rectal bleeding b. Delayed childbirth may lead to develop- 4. Symptoms classically occur before or during ment of endometriosis menses c. Treatment is long term; may become a 5. Pain may be localized to involved area chronic illness 6. Infertility d. Counsel regarding the risk of infertility

• Physical findings Adenomyosis 1. Fixed, retroverted uterus 2. Bilateral, fixed, tender adnexal masses • Definition—benign condition in which ectopic en- 3. Nodularity and tenderness of uterosacral liga- dometrium is found within the myometrium; often ments and cul-de-sac is considered a type of endometriosis 4. Tenderness, thickening, and nodularity of rectal–vaginal septum Menstrual and Endocrine Disorders 203

• Etiology/Incidence 3. Most common age for pituitary adenoma is 1. May be related to breakdown of the endome- sixth decade trium during labor and delivery; the cells of 4. High prolactin level found in around one-third the endometrial basal layer grow downward of women with amenorrhea of unknown ori- losing connection with the endometrium gin; about one-third of women with secondary 2. Incidence varies widely from 10–90% of hyster- amenorrhea will have pituitary adenoma; one- ectomies revealing adenomyosis third of women with high levels of prolactin 3. Diagnosis most common in parous women be- will have galactorrhea tween ages 40 and 50 5. Galactorrhea should be evaluated in a nulliparous woman or in a parous woman if 12 • Signs and symptoms months has passed since last pregnancy 1. Increasingly severe dysmenorrhea and heavy bleeding during menses are common • Signs and symptoms 2. Infertility 1. Hyperprolactinemia/galactorrhea a. Spontaneous clear or milky bilateral or • Physical findings unilateral breast secretions from multiple 1. Boggy tender uterus ducts 2. Diffuse, globular enlargement—may be 8 to 10 b. Normal or irregular menses; secondary weeks size amenorrhea may occur 3. May see evidence of anemia c. Disturbances of vision and headaches may be present (if adenoma is cause) • Differential diagnosis 2. Pituitary adenoma 1. Endometriosis a. Breast secretions 2. Leiomyomata b. Menstrual changes as described 3. Pregnancy c. Severe vascular headaches and blurred 4. Adhesions vision

• Diagnostic tests/findings • Physical findings 1. Ultrasonography or MRI may rule out other 1. Normal funduscopic examination—if no pathology adenoma 2. Endometrial biopsy for abnormal bleeding 2. Funduscopic examination may show papilledema if adenoma present • Management/Treatment 3. Normal physical and gynecological 1. Symptomatic relief may be only requirement examination 2. Hysterectomy may be indicated and is curative 3. NSAID for pain • Differential diagnosis 4. Hormone suppression—symptoms usually 1. Pregnancy/breast feeding subside after hormone production ceases 2. Breast cancer 3. Hypothyroidism, hyperthyroidism Hyperprolactinemia, Galactorrhea, and 4. Pituitary adenoma Pituitary Adenoma 5. Excessive breast stimulation 6. Disorders or injury of chest wall • Definition 7. Medication effect (e.g., endogenous opiates, 1. Hyperprolactinemia—elevated levels of cannabis, heterocyclic antidepressants) prolactin 8. Disturbances of ovarian function 2. Galactorrhea—secretion of a nonphysiologic, 9. Benign and malignant brain neoplasm milky fluid from the breast, unrelated to pregnancy • Diagnostic tests/findings

3. Pituitary adenoma—benign tumor of pituitary; 1. Thyroid screening—e.g., TSH, T4 most common type secretes prolactin 2. Serum prolactin—refer if more than 20 ng/mL; if in 100 to 300 ng/mL range—very suspicious • Etiology/Incidence for adenoma 1. Etiology and incidence of pituitary adenoma is 3. Serum hCG to rule out pregnancy unknown; rarely malignant, can grow for years 4. Microscopy of breast secretions—milk indi- 2. Prolactin-secreting adenomas account for 50% cated by fat globules of all identified at autopsy 5. CT or MRI of sella turcica to rule out adenoma 204 Chapter 7 Gynecological Disorders

• Management/Treatment c. Hypomenorrhea—too little bleeding at 1. Management may best be accomplished by normal intervals referral to a reproductive endocrinologist d. Menorrhagia—regular, normal intervals, 2. If prolactin level is less than 20 ng/mL, may excessive flow and duration follow with yearly prolactin levels e. Metrorrhagia—intermenstrual bleeding 3. Pharmacologic or bleeding occurring at times other than a. Dopamine agonist (e.g., bromocriptine, normal intervals which inhibits prolactin, provides symptomatic relief, decreases or stops galactor- • Physical findings—none specific rhea); treatment of choice with highest cure • Differential diagnosis b. Treat hypo/hyperthyroidism 1. Diagnosis of exclusion 4. Surgical 2. Pregnancy (ectopic or intrauterine) a. If medical management has failed to 3. Cervical and endometrial cancer, polycystic relieve symptoms of adenoma, transphe- ovarian syndrome (PCOS), liver disease, thy- noid neurosurgery may be indicated roid disease, blood dyscrasia, leiomyomata, b. Recurrence rate is 10–70%; requires close adenomyosis, trauma, vaginitis, foreign body, follow-up medication interaction 5. Radiation 4. Severe stress, drug abuse a. Results are less satisfactory than surgery b. May take several years for prolactin level • Diagnostic tests/findings to fall 1. hCG for pregnancy c. Should be reserved for recurrences 2. Pap test for cervical cancer or those not responsive to medical 3. Complete blood count management 4. FSH and LH to evaluate estrogen stimulation 6. Patient education 5. TSH a. Discontinue breast stimulation 6. Sexually transmitted disease testing as b. Disclose all drugs and medications being indicated used 7. Endometrial evaluation—biopsy, transvaginal ultrasound, saline infusion sonohysteroscopy Dysfunctional Uterine Bleeding (DUB) 8. Coagulation studies if indicated

• Definition—a variety of bleeding manifestations • Management/Treatment secondary to chronic anovulation 1. Hormonal a. Acute excessive bleeding—parenteral • Etiology/Incidence estrogen or high-dose oral estrogen gradu- 1. Disturbances of hypothalamic-pituitary- ally tapered then medroxyprogesterone axis may cause continuous endometrial acetate (MPA) added last 10 days to initi- stimulation ate withdrawal bleeding 2. DUB is abnormal bleeding that is unrelated to b. Moderate bleeding, not currently bleed- organic pathology, systemic conditions, medi- ing, and maintenance control—OCP cy- cations, genital tract pathology, or pregnancy clic, extended, or continuous regimens; 3. Risk factors—postpubertal and perimeno- DMPA; cyclic MPA; LNG-IUS pause phase, overweight or underweight, 2. Nonhormonal chronic illness, excessive stress a. Treat anemia 4. Most common menstrual abnormality in re- b. Nonsteroidal anti-inflammatory drugs productive age women (NSAIDS)—start at menses onset and continue for 5 days or until cessation of • Signs and symptoms menstruation 1. Usually occurs at the extremes of reproductive 3. Surgical management age—adolescence and perimenopause a. Hysterectomy 2. Patterns of dysfunctional bleeding b. Endometrial ablation a. Oligomenorrhea—normal bleeding at in- c. Dilatation and curettage is diagnostic and tervals greater than 35 days therapeutic b. Polymenorrhea—bleeding that is normal, occurring at intervals less than 21 days Benign and Malignant Tumors/Neoplasms 205

Â Benign and Malignant 2. Subserosal—bulge through the outer uterine Tumors/Neoplasms wall 3. Intraligamentous—within the broad ligament Cervical Polyps 4. Interstitial (intramural)—stays within the uterine wall as it grows; most common form of • Definition—pedunculated growths arising from myoma the mucosal surface of the endocervix 5. Pedunculated—on a thin pedicle or stalk attached to the uterus • Etiology/Incidence 1. Inflammation • Etiology/Incidence 2. Trauma 1. Etiology unknown 3. Pregnancy 2. May arise from smooth muscle cells in the 4. Abnormal local response to hypoestrogenic myometrium state 3. Most common benign gynecological pelvic 5. Occurs in 4% of all gynecological patients neoplasm 6. Most common benign neoplasm of the cervix; 4. Affects approximately 20% of women in their and most often seen in perimenopause and reproductive years multigravida women between ages 30 and 50 5. Occurs more frequently in African-American 7. Malignant changes are rare women than in Caucasian 6. Asymptomatic fibroids may be seen in 40–50% • Signs and symptoms of women over age 40 1. May be asymptomatic 7. Increased family incidence 2. Leukorrhea 3. Abnormal vaginal bleeding—intermenstrual, • Signs and symptoms postcoital 1. Usually asymptomatic 2. Menorrhagia—most common sign • Physical findings 3. Pelvic pain is most often chronic—presents as 1. Single or multiple, painless polypoid lesions at dysmenorrhea, pelvic pressure, or dyspareu- cervix nia; if pedunculated, twisted, and infarcted 2. Size ranges from a few millimeters to 2 to 3 cm may cause acute pain 3. Reddish-purple to cherry red in color; smooth 4. Large fibroids may cause constipation; intesti- and soft; bleeds easily nal obstruction may result from compression; 4. Otherwise normal pelvic examination venous stasis may occur from pressure; pressure on bladder may result in urinary retention • Differential diagnosis or overflow incontinence 1. Adenocarcinoma 2. Cervical carcinoma • Physical findings 3. Prolapsed myoma 1. Abdominal enlargement 4. Squamous papilloma 2. Enlarged, irregularly shaped, firm uterus; may 5. Retained products of conception be displaced 6. Sarcoma 3. Pedunculated tumor may protrude from cervix 4. Tumors usually painless on palpation • Diagnostic tests/findings 5. Wide variance in size (3 to 4 mm up to 15 lb) 1. Pap test to rule out premalignant cervical le- 6. Potential complications sions or cancer a. Spontaneous abortion 2. Biopsy to rule out cancer b. Premature labor c. Anemia • Management/Treatment d. Infertility 1. Excisional polypoidectomy is usually curative 2. Recur frequently • Differential diagnosis 1. Ovarian mass (benign or malignant) Leiomyomata Uteri (Fibroid, Myoma) 2. Pregnancy 3. Leiomyosarcoma • Definition—nodular, discrete tumors varying in 4. Uterine malignancy size from microscopic to large multiple, nodular 5. Adenomyosis masses; classified according to location 6. Endometriosis 1. Submucosal—protrude into the uterine cavity 7. Colon or rectal tumor (benign or malignant) 206 Chapter 7 Gynecological Disorders

• Diagnostic tests/findings • Etiology/Incidence 1. Pap test to rule out cervical cancer 1. Follicular cysts 2. Pregnancy test to rule out pregnancy a. Rare before menarche or after menopause 3. CBC if anemia suspected b. Account for 20–50% of ovarian cysts; most 4. Occult blood test if rectal or colon symptoms common adnexal mass in reproductive or gastrointestinal problems years 5. Endometrial biopsy or D & C when abnormal c. Often found incidentally during routine bleeding present pelvic examination or ultrasound 6. Ultrasound, sonohysterogram, CT, MRI con- d. Usually resolves in 2 to 3 menstrual cycles, firm diagnosis may rupture or undergo torsion causing 7. Hysteroscopy to provide visualization of uter- pain ine cavity 2. Corpus luteum cysts a. Forms following the failure of the corpus • Management/Treatment luteum to degenerate after 14 days 1. May require no treatment if asymptomatic b. May hemorrhage into the cystic cavity 2. Periodic observation and follow-up with bi- 3. Dermoid cysts (benign cystic teratoma) manual examination may be indicated to a. One of the most common neoplasms of insure tumors are not growing or undergoing the ovary (10–20%) abnormal changes b. Occurs during the reproductive years 3. Pharmacologic c. Composed usually of well-differentiated a. GnRH agonist results in 40–60% reduction tissue from all three germ layers in volume; regrowth occurs about half the d. Usually measures 5 to 10 cm in diameter; time; may be used to reduce volume pre- 10–15% are bilateral operatively, before attempting pregnancy, when surgery is contraindicated, or in • Signs and symptoms perimenopausal women to avoid surgery 1. Functional cysts b. Progestational agents such as medroxy- a. Usually asymptomatic progesterone acetate (MPA) may decrease b. May cause irregular menses, pelvic pres- fibroid size and bleeding sure, fullness (if mass is large), increase in c. Treat anemia if indicated abdominal girth/distention 4. Surgical c. Acute pain if ruptures or if torsion occurs a. Indications for surgery d. Large cysts may cause feeling of fullness, (1) Abnormal bleeding heaviness, and dull ache on affected side (2) Rapid growth 2. Dermoid (benign cystic teratoma) (3) Definitive decision concerning mass if a. Usually asymptomatic impossible without visualization b. Acute pain if twists or ruptures; may expe- (4) Encroachment of organs rience peritonitis b. Hysterectomy when symptoms cannot be c. May cause vague feelings of local pelvic controlled pressure if large c. Myomectomy through hysteroscopic re- d. Abnormal uterine bleeding (rare) section can preserve fertility; up to 30% 3. Signs of rupture include severe, sudden ab- recurrence with this method dominal pain; mimics ruptured ectopic

Ovarian Cysts • Physical findings 1. Functional cysts are usually smaller than 8 cm, • Definition: cystic to firm, mobile, sometimes tender, usu- 1. Functional—cysts of the ovary that occur sec- ally unilateral adnexal mass ondary to hormonal stimulation 2. Dermoid cysts may measure 5 to 10 cm, usu- a. Follicular—occur in the follicular phase ally unilateral, firm to cystic, often anterior to of the menstrual cycle when continued uterus hormonal stimulation prevents fluid resorption • Differential diagnosis b. Corpus luteum—occur in the luteal phase, 1. Pregnancy; ectopic pregnancy when corpus luteum fails to degenerate 2. Ovarian torsion 2. Dermoid (benign cystic teratoma)—most 3. Uterine fibroid; endometrioma common ovarian germ cell tumor 4. Tubo-ovarian abscess 5. Diverticulitis/abscess Benign and Malignant Tumors/Neoplasms 207

6. Distended bladder b. Presence of HPV types with malignant 7. Congenital anomaly (pelvic kidney) potential (types 16, 18, and 31 most 8. Lymphadenopathy common) 9. Malignant neoplasm (most often in older c. First coitus at early age (< 18 years) women) d. Multiple sexual partners or sexual partners with multiple partners • Diagnostic tests/findings e. Nonbarrier method of contraception 1. Pregnancy test f. Immunosuppression 2. Ultrasound to evaluate mass—cystic or g. Long-term oral contraceptive use ($ 5 solid; septate, irregular, presence of papilla- years) tions, bilateral or unilateral; rule out ectopic h. Never had Pap test or infrequent Pap tests pregnancy 3. CT scan with contrast or IVP to evaluate • Signs and symptoms kidney 1. May be asymptomatic 2. Postcoital or irregular, painless bleeding • Management/Treatment 3. Odorous bloody or purulent discharge 1. Functional cyst 4. Late symptoms a. In reproductive years; cyst less than 6 cm a. Pelvic or epigastric pain in diameter, examine after next menses b. Urinary or rectal symptoms b. Combination hormonal contraceptives to suppress gonadotropin levels • Physical findings c. Mass between 6 and 8 cm, or is fixed or 1. Appearance of cervix ranges from normal to feels solid, pelvic ultrasound to assure is severely ulcerated, necrotic or large bulky le- unilocular sion filling the vagina d. If painful, multilocular, or partially solid, 2. Cervix may be firm or “rock like” to soft and surgery indicated spongy e. 8 cm, surgery indicated 3. Sanguineous or purulent, odorous vaginal f. If 40 years old or older, use more caution discharge and observe 4. Anemia if bleeding heavy 2. Dermoid cyst—determined by age, desire for pregnancy and potential for malignancy; cys- • Differential diagnosis tectomy or abdominal hysterectomy and bilat- 1. Metastasis from another primary site eral salpingo-oophrectomy 2. Cervicitis/sexually transmitted infections 3. Cervical polyp Cervical Carcinoma 4. Cervical ectopy 5. Pre-invasive lesion of cervix • Definition—slow penetration of the basement 6. Condyloma acuminata membrane and infiltration of malignant cells into the uterine cervix; characterized by histologically • Diagnostic tests/findings defineable stages 1. Pap test is gold standard for cost-effective screening • Etiology/Incidence 2. Biopsy of gross lesions 1. Approximately 14,500 new cases diagnosed 3. If malignancy is suspected, but no gross lesion annually with 4000 to 5000 deaths visible, colposcopy is suggested with biopsy 2. Highest incidence in Hispanics, then African 4. Colposcopic evaluation of vulva and vagina to Americans, then Caucasians rule out other lesions 3. Peak incidence between 45 and 55 years of age; 5. CT, MRI, cystoscopy, sigmoidoscopy, and bar- increasing in young women ium enema may be indicated 4. Time between initial exposure to a carcinogen and subsequent development of carcinoma • Management/Treatment in-situ considered to be 5 to 10 years 1. Management should be by a gynecological on- 5. HPV is the primary agent in the development cologist involving staging, appropriate treat- of cervical intraepithelial neoplasia (CIN) and ment and follow-up cervical cancer 2. Treatment may consist of surgery, radiation, 6. Risk factors chemotherapy, or a combination a. Smoking 208 Chapter 7 Gynecological Disorders

Endometrial Carcinoma 4. Fractional dilatation and curettage is the gold standard for diagnosis • Definition—carcinoma of the body of the uterus; 5. Hysteroscopy may be useful in identifying le- malignant transformation of endometrial glands sions/polyps not found on biopsy and/or stroma • Management/Treatment • Etiology/Incidence 1. Refer to gynecologist for early stage disease or 1. Most common gynecological malignancy— oncologist accounts for 90–95% of malignancies of the 2. Hysterectomy, bilateral salpingo- uterine corpus oophorectomy 2. 30,000 new cases annually and 6000 deaths 3. Surgical staging to determine treatment 3. Median age is 63 years at onset—5% occurring 4. Radiation, chemotherapy, steroids (progester- in women younger than age 40 one), or combination 4. Risk factors are linked to exposure to unopposed estrogen either endogenous or Ovarian Carcinoma exogenous a. Diabetes, obesity, hypertension • Definition—a malignant neoplasm of the ovary b. Family history c. Early menarche; late menopause • Etiology/Incidence d. Unopposed estrogen therapy 1. Malignancies of the ovary arise from any type e. Oligo-ovulation, anovulation of cell found in the ovary; epithelial carcinoma f. Estrogen secreting tumors (granulosa cell) is the most common type (80–85%) 5. Protective factors—multiparity, use of oral 2. Ovary may be site for metastasis from noncontraceptive pills, use of depot medroxypro- ovarian cancers gesterone acetate (DMPA) 3. Etiology unknown 4. Risk factors • Signs and symptoms a. Family history in one first-degree rela- 1. Painless vaginal bleeding is typically the first tive—10% chance symptom b. Family history in two first-degree rela- 2. Serous, odorous discharge (watery leukor- tives—50% chance rhea), soon replaced by bloody discharge, c. Family susceptibility shown with the intermittent spotting, spotting-to-steady pain- BRCA1 gene less bleeding, then hemorrhage d. Low parity 3. Lower abdominal pain (10%) e. Early menarche; late menopause f. Ovulation induction agents (possibly) • Physical findings g. Perineal talc use (suggested) 1. Blood may be present in the vaginal vault h. High socioeconomic class 2. Advanced disease may have pelvic mass pres- i. High dietary fat consumption ent, ascites j. History of breast, colon, or endometrial 3. Anemia may be present cancer 4. Uterus may be enlarged and soft 5. Use of oral contraceptives reduces risk—protection lasts up to 2 decades after last use • Differential diagnosis 6. Fifth most common cancer in women 1. Atrophic vaginitis 7. Second most common genital tract cancer 2. Cervical or endometrial polyps 8. 25,000 new cases annually 3. Benign endometrial pathology (hyperplasia) 9. Usual age of onset is near the perimenopause 4. Dysfunctional uterine bleeding or menopause—median age 61 years, peaks at 5. Bleeding from hormone replacement therapy 75 to 79 6. Leiomyomas 10. Mortality rate exceeds all other genital tract 7. Other genital/gynecological cancers malignancies; presents in advanced stage

• Diagnostic tests/findings • Signs and symptoms 1. Pap test may show glandular abnormalities 1. Early 2. Endometrial aspiration biopsy a. Often asymptomatic; may be detected on 3. Ultrasound to measure endometrial stripe; if routine pelvic examination less than 5 mm thick, likelihood of endome- b. Symptoms are often mild, vague, and trial cancer is rare inconsistent Benign and Malignant Tumors/Neoplasms 209

c. Abdominal discomfort or pain • Etiology/Incidence d. Pressure sensation on the bladder or 1. Comprises about 2% of malignancies—vaginal rectum cancer is the rarest of gynecological cancers e. Pelvic fullness or bloating 2. Mean age of diagnosis 65 years with a range of f. Vague gastrointestinal symptoms 30 to 90 years 2. Late 3. Etiology is multifactorial; risk factors include a. Increasing abdominal girth presence of HPV infection, other genital can- b. Abdominal pain cers, DES exposure, prior radiation c. Abnormal vaginal bleeding 4. Vaginal intraepithelial neoplasm is thought to d. Gastrointestinal symptoms; nausea, loss of be a precurser appetite, dyspepsia 5. Five-year survival ranges from 80% for stage I to 17% for stage V • Physical findings 1. Palpation of fixed, irregular, nontender ad- • Signs and symptoms nexal mass—usually bilateral (usually first 1. May present with vaginal bleeding or odorous diagnostic finding) blood tinged discharge—may cause vulvitis or 2. Ascites pruritus 3. Pleural effusion and subclavicular lymphade- 2. May have palpable or visible mass or lesion nopathy if advanced 3. Urinary problems if bladder involved 4. Cachexia • Physical findings • Differential diagnosis 1. Early lesions are raised, granular and may be 1. Primary peritoneal cancer white 2. Benign ovarian tumor 2. Late lesions are friable, granular, cauliflower- 3. Endometriosis like and may be palpable; ulceration may be 4. Functional ovarian cyst superficial or deep 5. Ovarian torsion 3. Most common site is upper one-third of vagina 6. Pelvic kidney 4. If lesion darkly pigmented—suspect 7. Pedunculated uterine fibroid melanoma

• Diagnostic tests/findings • Differential diagnosis 1. Pelvic ultrasonography/CT/MRI 1. Malignancy of another site extended or meta- 2. CA-125—elevated levels not diagnostic for static to the vagina ovarian cancers (elevations can occur with 2. Vaginitis endometriosis, leiomyomata, pelvic inflamma- 3. Bleeding from uterus tory infection, hepatitis, and other malignan- 4. Ulceration from foreign object (pessary, cies); helpful to follow response to treatment tampon) with chemotherapy and subsequent follow-up 3. Definitive diagnosis is made with laparotomy • Diagnostic tests/findings 1. Pap test to evaluate for cervical cancer • Management/Treatment 2. Colposcopy and biopsy of lesions 1. Surgical 3. For staging use cystoscopy, proctosigmoidos- a. Total abdominal hysterectomy, bilateral copy, IV urography, chest radiography, barium salpingo-oophorectomy, and omentec- enema tomy—establishes histologic staging and 4. CT scan and MRI are used to evaluate grading of tumor metastasis b. Goal is removal of as much tumor as possible • Management/Treatment 2. Chemotherapy and/or radiation 1. Treatment should be by a gynecological 3. Rule out metastasis with diagnostic evaluation oncologist of other organ systems 2. Accurate diagnosis and stage is to be determined before treatment is planned Vaginal Carcinoma 3. If lesion is precancerous (VAIN I, II, III), laser is appropriate • Definition—abnormal proliferation of vaginal epi- 4. Local excision (partial vaginectomy) may be thelium with malignant cells extending below the appropriate for early lesions basement membrane 210 Chapter 7 Gynecological Disorders

5. Radiation is mainstay of treatment • Diagnostic tests/findings 6. Radical surgery may be followed with radiation 1. Pap test, colposcopy to rule out other sites of disease Vulvar Carcinoma 2. Biopsy/wide resection to make definitive diagnosis • Definition—proliferation of malignant cells of 3. CT and MRI, chest radiography to evaluate for vulva metastasis

• Etiology/Incidence • Management/Treatment 1. Multifactorial 1. Appropriate evaluation by a gynecological 2. Increased risk in women with the human pap- oncologist illomavirus (HPV) (30–50%) 2. Local excision 3. Risk factors 3. Simple or radical vulvectomy a. History of abnormal Pap test 4. Topical treatment—immunologic agents, b. Multiple sexual partners chemotherapy c. Cigarette smoking 5. Careful follow-up—recurrence is common d. Chronic irritation e. Vulvar dermatoses Choriocarcinoma 4. May be associated with other urogenital cancers • Definition—a frankly malignant form of gesta- 5. Accounts for 1–2% of all gynecological cancer tional trophoblastic disease or may be primary in deaths per year the ovary 6. Vulvar malignancies arise from squamous cell carcinoma, melanoma, adenocarcinoma, basal • Etiology/Incidence cell carcinoma, and sarcomas 1. Gestational trophoblastic disease 7. Mean age 65 with a range of 30 to 90 years; in- a. May follow any gestational event—intra- cidence in young women is rising uterine or ectopic pregnancy, abortion (50%); hydatidiform mole (50%) • Signs and symptoms b. Malignant transformation occurs in the 1. May be asymptomatic chorion 2. Lesions may be darkly or irregularly pig- c. One of the few metastatic tumors that is mented, white or red; multifocal or singular; curable flat, wart like, or scaly 2. Nongestational—mixed germ cell tumor of 3. Ulceration, erythema, irritation ovary occurring in childhood or early adoles- 4. Pruritus (most common), pain, burning, cence; unusual in ages 20 to 30 bleeding 3. Disseminates by blood to the lungs, vagina, 5. Odorous discharge, may be blood-tinged brain, liver, kidneys, and gastrointestinal tract

• Physical findings • Signs and symptoms—often masquerades as other 1. White, red, pigmented or ulcerated lesion disease due to metastasis to other organs 2. Hyperkeratotic patches (leukoplakia) 1. Irregular vaginal bleeding—intermittent to 3. Excoriation and erythema hemorrhage; continuing after immediate post- 4. Most common sites are labia majora and partum period; uterine subinvolution minora 2. Amenorrhea (from gonadotropin secretion) 5. Bartholin’s gland enlargement 3. Hemoptysis, cough, dyspnea with lung 6. Inguinal lymphadenopathy metastasis 4. Evidence of central nervous system metasta- • Differential diagnosis sis—headache, dizziness, fainting 1. Vulvar dermatoses 5. Gastrointestinal—rectal bleeding/tarry stools 2. Atrophy 6. Abdominal pain 3. Condyloma acuminata 7. Hematuria from renal metastasis 4. Vulvar infection/inflammation 5. Lymphogranuloma inguinale • Physical findings 6. Paget’s disease 1. Abdominal mass/ascites 2. Blood in vaginal vault 3. Vaginal or vulvar lesion may indicate metastasis Vaginal Infections 211

4. Enlarged, soft uterus 6. Most common vaginal infection in the US, 5. Abnormalities of multiple organs if metastatic about 10 million patient visits per year

• Differential diagnosis • Signs and symptoms 1. May imitate other diseases—suspect strongly 1. Most often asymptomatic if follows a pregnancy event 2. Pruritus occasionally 2. Intrauterine pregnancy 3. Heavy grayish, yellowish, whitish, odorous, 3. Invasive mole homogenous vaginal discharge; may coat the 4. Benign ovarian tumor vulva 5. Other gynecological malignancies 4. Rancid or fishy odor during menses and postcoitally • Diagnostic tests/findings 1. Quantitative hCG • Physical findings 2. Abnormal beta hCG regression titers following 1. Copious amount of homogenous, whitish gray molar pregnancy vaginal discharge 3. CT scan abdomen, pelvis, and head 2. Normal appearing vulva and vaginal mucosa 4. Lumbar puncture may be necessary 3. Discharge may coat vulva 5. Chest radiography 4. Presence of foul odor

• Management/Treatment • Differential diagnosis 1. Should be managed by a gynecological 1. Trichomoniasis oncologist 2. Candidiasis 2. Treatment is usually with surgery and chemotherapy or chemotherapy alone • Diagnostic tests/findings 3. Appropriate follow-up to monitor side-effects, 1. Wet mount of vaginal secretions disease improvement, and recurrence 2. Presence of three of the following criteria is 4. Nonmetastatic—good prognosis; metastatic— diagnostic: good to poor prognosis a. Vaginal pH greater than or equal to 4.5 b. Clue cells on saline wet mount (epithelial Â Vaginal Infections cells with borders obscured as a result of stippling with bacteria) Bacterial Vaginosis (BV) c. Homogeneous discharge, white, noninflammatory discharge smoothly coating • Definition—an alteration of the normal flora of the vaginal wall vagina with dominance of anaerobic bacteria d. Positive “whiff test”—fishy odor of vaginal discharge before and after addition • Etiology/Incidence of 10% KOH; (caused when anaerobic 1. Loss of lactobacilli (hydrogen producing bacteria combined with potassium hy- strains) results in elevated pH and subsequent droxide); may also have positive whiff overgrowth of bacteria—bacteria concentra- test in the presence of blood, semen, and tions are 100- to 1000-fold trichomonas 2. No single offending organism—Gardnerella 3. Commercially available card tests for detection vaginalis, Mycoplasma nominis, Bacteroides of elevated pH, presence of amine species, Haemophilus, mobiluncus, corynebac- 4. Gram stain reveals true clue cells, numerous terium are among the anaerobes abnormal bacteria 3. BV is not a “vaginitis” and is not sexually trans- 5. Cultures for anaerobes are unnecessary mitted; increased bacteria numbers without inflammation (no increase in white blood • Management/Treatment cells, WBC); succinic acid produced by organ- 1. Metronidazole orally for 7 days isms alter migration of WBC to bacteria at el- 2. Metronidazole gel one full applicator intra- evated pH vaginally at bedtime for 5 days 4. Risk factors include multiple sexual partners, 3. Clindamycin cream one full applicator intra- new sex partner, shared sex toys, and douching vaginally at bedtime for 7 days 5. May be associated with intra-amniotic infec- 4. Alternative regimens tion, postpartum and postoperative infection, a. Clindamycin orally for 7 days endometritis, pelvic inflammatory disease b. Clindamycin ovules intravaginally at bed- (PID) time for 3 days 212 Chapter 7 Gynecological Disorders

5. Treatment of partner will not change course of 3. Infection may be found in endocervix, vagina, disease or prevent recurrences bladder, Bartholin’s glands, and periurethral 6. Key points concerning metronidazole glands a. May cause a disulfiram effect (flush- 4. Homogeneous, watery, yellowish green, graying, vomiting) if taken when alcohol is ish, frothy vaginal discharge consumed 5. pH greater than or equal to 5.0 b. Side-effects; metallic taste, nausea, head- 6. Cervix may bleed easily when touched ache, dry mouth, dark colored urine c. May cause disturbance in depth • Differential diagnosis perception 1. Bacterial vaginosis d. Not to be taken with anticoagulants—may 2. Candidiasis prolong prothrombin time 3. Trauma from foreign body 7. Treatment in pregnancy—see Pregnancy chapter • Diagnostic tests/findings 1. Saline wet mount (60–70% sensitive), higher Trichomoniasis sensitivity with immediate evaluation of wet preparation slide—motile trichomonads; in- • Definition—vaginal infection caused by an anaero- creased WBC bic flagellated protozoan parasite 2. Gram stain—no advantage over wet mount 3. Definitive test—culture • Etiology/Incidence 4. Urine microscopic examination may reveal 1. Pathogenesis unknown; humans are the only live trichomonads host 5. Detection on Pap test 40% positive predictive 2. Caused by the trichomonas organism; survives value best in a pH of 5.6 to 7.5 6. Rapid tests (results in 10–45 minutes) on vagi- 3. Sexually transmitted; theoretically possible nal secretions (> 82% sensitive, > 97% specific) fomite spread but unlikely 4. Responsible for 25% of vaginal infections— • Management/Treatment females symptomatic (25%); men rarely 1. Metronidazole orally in a single dose symptomatic 2. Tinidazole orally in single dose 5. Risk factors include multiple sexual partners, 3. Alternative regimen—metronidazole orally presence of another STD, noncondom use twice daily for seven days 6. Use of barrier contraceptive methods may de- 4. For treatment failures—exclude reinfection; crease prevalence retreat with metronidazole orally twice a day 7. May be associated with premature rupture of for 7 days or tinidazole orally in a single dose the membranes and preterm labor 5. All sexual partners should be treated 6. Pregnancy—see Pregnancy chapter • Signs and symptoms 7. Screen for other sexually transmitted infec- 1. Symptoms variable; may be asymptomatic tions as indicated 2. Any combination of the following symptoms 8. Encourage “safer sex practices” to reduce rein- may be seen; copious, homogeneous, mal- fection and chance of other STD odorous, yellowish-green discharge, vulva irritation, pruritus and edema, and occasionally Vulvovaginal Candidiasis (VVC) dysuria, urgency, frequency of urination, postcoital and intermenstrual bleeding • Definition—inflammatory vulvovaginal process 3. Erythema of vulva and vagina with excoriation caused by the yeast organism, candida species, may be seen which superficially invades the epithelium cells 4. Onset of symptoms often occurs after menses • Etiology/Incidence • Physical findings 1. Second most common vulvovaginal infec- 1. Erythema, edema, excoriation of vulva may be tion—caused by candida, a dimorphic fungi seen 2. 75% of women will have at least one episode 2. Red stipples—“strawberry spots”—on vagina in their reproductive years; 45% will have a and cervix (punctate lesions called colpitis second episode; 5% or less will have recurrent macularis) intractable episodes; up to 20% of women in their childbearing years will have yeast Sexually Transmitted Diseases (STD) 213

isolated; 20–30% will have dual or multiple 2. Azole family of antifungals is usual treatment pathogens and more effective than nystatin 3. C. albicans species is responsible 85–90% of 3. Single dose or 3-day topical azole regimens the time; C. glabrata and C. tropicalis are re- effective for uncomplicated VVC sponsible for majority of remaining infections 4. Fluconazole orally in a single dose and more resistant to therapy 5. Treatment for recurrent VVC—if four or more 4. Predisposing factors to candidal overgrowth symptomatic episodes in one year; usually no include pregnancy, reproductive age group, apparent predisposing factor; culture to deter- uncontrolled diabetes, immunosuppressive mine if nonalbicans candida species; consider disorders, frequent intercourse, antibiotic use, longer duration therapy and maintenance reg- high-dose corticosteroids imens (several regimens suggested with both topical azoles and oral fluconazole) • Signs and symptoms 6. Key points 1. May have a combination of the following: a. Azole creams and suppositories are oil- a. Irritation of vulva, pruritus, soreness, ex- based and may weaken latex condoms and ternal dysuria, excoriation diaphragms b. Edema b. Treatment of partner is not recommended c. Erythema unless male has balanitis d. Discharge may be thick, curdy, thin or wa- c. Severe VVC (extensive erythema, edema, tery, with yeast odor fissure formation) usually requires 7–14 e. Dyspareunia (upon penetration) day topical azole regimen or repeat dose of fluconazole 72 hours after initial dose • Physical findings d. Women with uncontrolled diabetes or 1. Discharge is usually adherent to the vaginal receiving corticosteroid therapy who wall have VVC may require 7–14 day treatment 2. Erythema of vulva and vagina regimen 3. Cervix appears normal on speculum e. Pregnancy—see Pregnancy chapter examination Â Sexually Transmitted • Differential diagnosis Diseases (STDs) 1. Trichomoniasis 2. Bacterial vaginosis Chlamydia 3. Vulvar dermatoses 4. Allergic reaction • Definition—infection of epithelial cells of the geni- 5. Urethritis/cystitis tal tract of men and women; may cause pneumonia and/or conjunctivitis in neonates • Diagnostic tests/findings 1. Wet mount of vaginal secretions with 10% po- • Etiology/Incidence tassium hydroxide (KOH) will reveal mycelia, 1. Caused by an intracellular organism, Chla- spores, and pseudohyphae mydia trachomatis, which replicates in the 2. Vaginal pH usually normal (< 4.5); amine test host causing inclusions in stained cells negative 2. Most common STD in the US—approximately 3. Increased WBC on wet mount 4 million acquired infections annually (report- 4. Fungal culture confirms diagnosis ing not required in all states) 5. Gram stain may be positive 3. Chlamydia infection may be the etiology of 6. Pap test 50% sensitive 50% of pelvic infections 7. Routine cultures may detect asymptomatic 4. May be transmitted vertically to the neonate in colonization; not performed routinely—may up to 70% of untreated women (conjunctival be used in recurrences or pneumonic infection) 5. Sequelae of chlamydia include cervicitis, en- • Management/Treatment dometritis, PID, ectopic pregnancy, infertility, 1. Treatment indicated if: acute urethral syndrome, postpartum infec- a. Symptomatic tions, premature labor and delivery, prema- b. Patient desires ture rupture of the membranes, and perinatal c. Is immunosuppressed morbidity 214 Chapter 7 Gynecological Disorders

6. Risk factors 7. Sex partners should be evaluated, tested, and a. Sexually active women under age 25 treated if they had sex contact with patient b. Multiple partners or partners with mul- during the 60 days preceding onset of symp- tiple sexual partners toms in the patient or diagnosis of chlamydia c. Nonuse of barrier methods of 8. The most recent sex partner should be evalu- contraception ated and treated even if the time of the last sexual contact was more than 60 days before • Signs and symptoms symptom onset or diagnosis (CDC 2006) 1. May be asymptomatic 9 Avoid intercourse until all partners have been 2. Postcoital bleeding; intermenstrual bleeding treated or spotting 10. Test of cure 3. Symptoms of urinary tract infection—dysuria, a. Not recommended if treated with CDC- frequency recommended or alternative regimens 4. Vaginal discharge and not pregnant 5. Abdominal pain b. Consider test of cure if suspect noncompliance with treatment or if symptoms • Physical findings persist 1. Mucopurulent endocervical discharge; c. Wait at least 3 weeks after treatment to do edematous, tender cervix with easily induced test of cure—prior to 3 weeks may get false bleeding negative 2. Suprapubic pain or slight tenderness upon d. Majority of posttreatment infections are palpation reinfection—retest at 3 months posttreatment or next office visit • Differential diagnosis 1. Gonococcal infection Condyloma Acuminata, Venereal Warts 2. Urethritis or urinary tract infection 3. Salpingitis • Definition—a sexually transmitted, viral disease affecting the vulva, vagina, cervix, and perianal area • Diagnostic tests/findings—presence of organism in various laboratory tests is basis for diagnosis • Etiology/Incidence 1. Culture—expensive 1. Caused by human papillomavirus (HPV) 2. Nonculture methods—nucleic acid amplifica- 2. Approximately 100 species of HPV; more than tion test (NAAT) recommended by CDC (2006) 30 types infect anogenital mucosal surfaces; 3. Gonococcal (GC) culture or nonculture test to potential for malignancy is variable (low-risk rule out concomitant gonorrhea and high-risk HPV types); may be infected 4. Serologic testing for syphilis, wet mount test- with multiple types simultaneously ing for vaginal infection, consider HIV screen 3. Sexually transmitted by skin-to-skin contact through viral shedding; fomite spread is pos- • Management/Treatment sible but rare 1. CDC (2006) recommendations 4. Highly contagious—25–65% of partners de- a. Azithromycin orally, single dose velop HPV b. Doxycycline orally for 7 days 5. Incubation period 4 to 6 weeks 2. Alternative regimens 6. The most common viral, sexually transmitted a. Erythromycin base orally for 7 days infection in the US b. Erythromycin ethylsuccinate orally 7 days 7. Genital warts most commonly associated with c. Ofloxacin orally 7 days low-risk types of HPV (6, 11) d. Levofloxacin orally for 7 days 8. Persistent infection with high-risk types of 3. Treatment in pregnancy—see Pregnancy HPV is associated with almost all cervical chapter cancers and many vulvar, vaginal, and anal 4. Doxycycline should not be used in pregnancy; cancers may cause discoloration of teeth in children 9. About 10% of women infected with HPV de- 5. Erythromycin estolate is contraindicated velop persistent HPV infections in pregnancy because of drug-related 10. Risk factors hepatotoxicity a. Previous or current other STD 6. Quinolones (ofloxacin, levofloxacin) are con- b. First intercourse at an early age (< 16 traindicated in pregnancy years); multiple sexual partners Sexually Transmitted Diseases (STD) 215

c. Male partner who has (or has had) mul- a. Cryotherapy with liquid nitrogen; repeat tiple partners every 1 to 2 weeks for 6 weeks d. Factors that suppress the immune b. Excision with tangential shave excision, system—diabetes, pregnancy, steroid curettage, electrocautery, or scissors or hormones, folate deficiencies, immuno- excision with laser suppressive diseases 6. Chemical or keratolytic agents a. Trichloracetic or bichloracetic acid • Signs and symptoms (80–90% solution); apply small amount 1. Wartlike lesions—pedunculated conical or carefully to wart, allow to dry; will turn cauliflower appearance; granular, rough tex- white; apply sodium bicarbonate or talc to ture to skin neutralize or remove unreacted acid; may 2. Lesions may be singular, multiple, or in clus- reapply weekly; safe in pregnancy ters on perineum, vulva, vagina, cervix, and b. Podophyllin resin (10–25%) in compound peri-anal area tincture of benzoin—CDC recommends 3. Perianal area may bleed easily, be painful, application of small amount to each wart, odorous, and pruritic wash off in 1 to 4 hours; repeat weekly 4. Color usually whitish to pinkish gray up to 6 weeks; pregnancy risk category C; 5. May have associated heavy, malodorous dis- contraindicated when breastfeeding charge (BV) c. If lesions are not resolved at the end of 6 weeks of treatment, reevaluate, change • Physical findings treatment, or refer 1. Wartlike lesions—conical, cauliflower appear- 7. Patient-applied treatment ance; may be multiple anywhere on perineum, a. Imiquimod 5% cream applied sparingly at perianal area, vagina, and cervix bedtime three times a week; area washed 2. May appear granular, macular, or cobblestone; with mild soap 6 to 10 hours after applica- may be subclinical or microscopic tion; safety in pregnancy is unknown 3. Color varies pink to gray; darkly pigmented— b. Podophilox 0.5% gel or solution; applied have high suspicion for malignancy sparingly to visible warts; safety in preg- 4. Many times will have concomitant BV nancy is unknown c. Use only on external warts • Differential diagnosis 8. Immunotherapy—interferon 1. Verrucous carcinoma 9. Combination therapy may be useful, especially 2. Normal variants of skin tags in single-treatment failures 3. Molluscum contagiosum 10. Refer if treatment fails or if lesions are darkly 4. Condyloma lata pigmented, indurated, ulcerated, suspicious, 5. Seborrheic keratosis or other benign skin or biopsy positive for HPV type with malignant disorders potential 11. Rule out high grade squamous intraepithe- • Diagnostic tests/findings lial lesion (HGSIL) before treating cervical 1. Diagnosis is made by visual inspection condyloma 2. Biopsy if diagnosis uncertain; no response to 12. Emphasize importance of regular Pap test or worsening during standard therapy; patient 13. HPV vaccination of all young girls and women immunocompromised; warts pigmented, in- (recommended for ages 11–26) durated, bleeding, ulcerated 3. Serologic testing for syphilis; testing for other Gonorrhea (GC) STDs; wet mount testing for vaginal infections; consider HIV testing • Definition—a sexually transmitted bacterial infection with an affinity for columnar and transitional • Management/Treatment epithelium 1. Goal of treatment is to eliminate present visible disease • Etiology/Incidence 2. If untreated may resolve on own, persist, 1. Neisseria gonorrhea—gram negative, intracel- remain unchanged, or increase in size or lular diplococcus requiring carbon dioxide number environment to survive 3. Keep area dry and clean 2. Sites for uncomplicated GC may be urethra, 4. Advise condom use endocervix (most common), Skene’s glands, 5. Physical agents Bartholin’s glands, and/or anus 216 Chapter 7 Gynecological Disorders

3. Most commonly sexually transmitted; neonate 2. Culture on Thayer-Martin medium may become infected during birth 3. Nonculture methods—nucleic acid amplifica- 4. Incubation period 3 to 5 days tion test (NAAT) recommended by CDC (2006) 5. Over 1 million cases reported annually, may be 4. Serologic testing for syphilis; chlamydia test- as many as 2 million ing; consider HIV screen 6. Occurs in individuals under age 30 approximately 80% of the time • Management/Treatment 7. Male-to-female transmission estimated at 1. CDC recommendations for uncomplicated 50–90%; female to male transmission 20–25% infections of cervix, urethra, and rectum 8. Since 1976 penicillinase-producing strains a. Cefixime orally in single dose (97.1% cure) have been present—some are now resistant to b. Ceftriaxone IM in a single dose (99.1% tetracycline, spectinomycin, or quinolones cure) 9. Risk factors c. Alternative regimen if can not tolerate a. Sexually active women under age 25 cephalosporins—spectinomycin IM in a b. Multiple sexual partners or partners with single dose (98.2% cure) multiple partners d. Patient should also be treated for chla- c. History of STD mydia if not ruled out d. Inconsistent condom use 2. Treatment in pregnancy—see Pregnancy e. Commercial sex work chapter f. Illicit drug use 3. Key points a. Patients treated for GC routinely also • Signs and symptoms treated with a regimen effective against 1. May be asymptomatic or symptomatic at sev- uncomplicated chlamydia eral sites—anal, vaginal, pharynx, joints b. Avoid sexual intercourse until all partners 2. Anal bleeding are treated 3. Pharyngeal erythema and exudate c. Treat all sexual partners presumptively 4. Pelvic discomfort; dysuria 5. Vulvar pain (Skene’s, Bartholin’s glands) Herpes Simplex (Genital Herpes 6. Joint pain; erythema and inflammation of Simplex, HSV) joints 7. Potential complications • Definition—a common, incurable, recurrent, viral a. Septic arthritis and bacteremia disease b. Skin lesions, pharyngitis; proctitis c. PID; perihepatitis • Etiology/Incidence d. Infections of glands (Skene’s, Bartholin’s) 1. Causative organism—two serotypes of the her- e. Gonorrhea ophthalmia neonatorum (in pes simplex virus neonates) a. Type I (HSV-I) commonly found in the f. Premature rupture of the membranes, mouth, accounts for 15% of genital chorioamnionitis, and prematurity infections b. Type II (HSV-II) causes 85% of genital • Physical findings infections 1. May have purulent discharge, inflamed Skene’s 2. Approximately 45 million people infected; 1 or Bartholin’s glands million new cases each year 2. 20% invade uterus after menses with symp- 3. 80–90% of people with HSV-II infection report toms of endometritis, salpingitis, or pelvic no history of signs/symptoms peritonitis 4. Asymptomatic shedding of virus accounts for the majority of transmission • Differential diagnosis 5. Usually transmitted by skin-to-skin contact; 1. Nongonococcal mucopurulent cervicitis rarely spread by fomite transmission (MPC) 6. 80–90% chance a female will develop herpes 2. Chlamydia following sexual contact with an infected male 3. Vaginitis 7. Risk factors a. Previous or present infection with an STD • Diagnostic tests/findings b. Trauma to skin (port of entry of virus) 1. Gram stain of no value in women (60–70% c. Immunosuppressed individual false negative) d. Multiple sexual partners Sexually Transmitted Diseases (STD) 217

8. Complications • Physical findings a. Herpes encephalitis 1. Small, painful, vesicles, and ulceration at vary- b. Herpes meningitis ing stages of progression c. Diffuse infection in immunocompromised 2. Exquisite pain at site of lesion individuals 3. Inguinal lymphadenopathy d. Perinatal infection 9. Genital herpes and pregnancy • Diagnostic tests/findings a. Most women who infect their neonates 1. Gold standard is an HSV culture properly col- have no known history of HSV lected from the base of the vesicle or ulcer b. Infection is transmitted during labor and and properly transported to a high-quality delivery laboratory 2. Pap test—low sensitivity, high specificity • Signs and symptoms—three HSV syndromes (pri- 3. Nonculture methods—PCR assay for HSV DNA mary infection, nonprimary first episode infection 4. Type-specific serologic tests (TSST) are avail- and recurrent infection) able to identify HSV-I and HSV-II antibodies; 1. Primary infection sensitivity 91–100%, specificity 92–98% at 6–12 a. Systemic symptoms—two-thirds will have weeks after initial infection systemic symptoms; fever, malaise, head- 5. Serologic testing for syphilis; tests for other ache; symptoms usually begin within 1 STD; consider HIV testing week of exposure, peak within 4 days and subside over the next week • Management/Treatment b. Localized genital pain 1. HSV-I and II have no cure; systemic antivi- c. Course of genital lesions ral drugs partially control symptoms; do not (1) Local prodrome; pruritus, erythema eradicate the latent virus nor affect the risk, about 1 to 2 days before appearance of recurrence, frequency, or severity of the symp- lesions toms once drug is discontinued; suppressive (2) Formation of small, painful vesicles therapy may reduce viral shedding over labia majora, minora, mons pu- 2. Medical management bis and occasionally vagina (4 to 10 a. Acute treatment days) (1) Acyclovir orally for 7 to 10 days (3) Vesicles rupture forming shallow, (2) Famciclovir orally for 7 to 10 days painful, wet ulcerations lasting 1 to 2 (3) Valacyclovir orally for 7 to 10 days weeks b. Episodic recurrent treatment (4) Lesions heal without scarring (1) Acyclovir orally for 5 days d. Tender inguinal lymphadenopathy may be (2) Famciclovir orally for 5 days the last symptom to resolve (3) Valacyclovir orally for 5 days e. 75% will have a discharge c. Daily suppressive therapy f. 90% will have cervical involvement char- (1) Acyclovir orally twice a day acterized by vesiculation and tendency to (2) Famciclovir orally twice a day bleed easily (3) Valacyclovir orally once a day 2. First episode nonprimary—initial clinical epi- d. Severe—hospitalize for IV therapy sode in patients with previously circulating e. Sexual partners antibodies to HSV-I or HSV II (1) Asymptomatic—counsel, encourage a. Symptoms same as primary self-examination; condoms b. Few constitutional symptoms (2) Symptomatic—use same treatment c. Shorter, milder course regimen 3. Recurrent genital herpes infection f. Pregnancy—see Pregnancy chapter a. Symptoms same as primary—usually g. Special considerations milder (resolve 7 to 10 days) (1) Allergy, intolerance, and adverse reac- b. Usually no constitutional symptoms tion; rare—desensitization may be c. Shorter durations of symptoms necessary (1) Prodrome—1–2 days (2) HIV infection (2) Vesicles—3–5 days (a) Episodic infection may be pro- (3) Dry-out days—2–3 days longed or more severe in persons infected with HIV (b) Episodic or suppressive therapy is often beneficial 218 Chapter 7 Gynecological Disorders

(c) Acyclovir, famciclovir and vala- • Diagnostic tests/findings cyclovir are safe for use in immu- 1. Biopsy—cytoplasmic inclusions—molluscum nocompromised individuals in bodies recommended doses 2. Test for other STD in young adults 3. Nonpharmacologic symptom relief a. Cool, topical compresses with Burow’s so- • Management/Treatment lution as needed; will reduce swelling and 1. Usually resolve spontaneously without inflammation scarring b. Local hygiene; topical anesthetics; cool air 2. Superficial incision; express contents with with fan or hair dryer comedo extractor 3. Curettage with cautery Molluscum Contagiosum 4. For multiple lesions, cryotherapy with liquid nitrogen, silver nitrate • Definition—a mildly contagious viral epithelium 5. Treatment may cause scarring proliferation of the skin Syphilis • Etiology/Incidence 1. Caused by the virus Molluscum contagiosum, • Definition—a chronic infectious, sexually trans- an unassigned pox virus containing double- mitted process that progresses predictably through stranded DNA distinct stages 2. Occurs worldwide—more common in tropical and subtropical regions • Etiology/Incidence 3. Most common in children and young adults 1. Caused by Treponema pallidum 4. Transmitted by skin to skin, fomite, and 2. Organism enters skin through microscopic autoinoculation breaks in the skin during sexual contact 5. Incubation period 2 to 7 weeks 3. Incubation period 10 to 90 days, average 21 days • Signs and symptoms 4. Occurs worldwide, primarily involving adults 1. Reddish to yellow, waxy, smooth, firm, spheri- 20 to 35 years of age; has become epidemic cal papules; umbilicated apex contains central in the US; includes syphilis in pregnancy and plug; usually less than 20 lesions ranging from congenital syphilis pinhead size to 1 cm in diameter 5. Increased incidence associated with greater 2. Presents on trunk and lower extremities in use of illicit drugs and high-risk behavior as- children sociated with drug use 3. Presents on lower abdominal wall, inner thigh, 6. Racial differences in incidence are associated pubic area, genitalia in adults with social factors; higher incidence in urban 4. Usually asymptomatic; may have pain, pruri- areas tus, and inflammation 7. Approximately 90,000 cases annually in the US

• Physical findings • Signs and symptoms 1. Lesions are multiple, but usually number less 1. Four stages of syphilis than 20 a. Primary 2. Characteristic light-colored papules with an (1) May be asymptomatic umbilicated center (2) Primary lesion (chancre) arises at the 3. Lesions found on trunk, lower extremities, ab- point of entry—evident 10 to 90 days domen, inner thigh, genital area following contact (3) Painless, ulcerated with raised border • Differential diagnosis and indurated base, rolled edges— 1. Varicella spontaneously disappears in 1 to 6 2. Lichens planus weeks 3. Warts/condyloma (4) May appear anywhere the organism 4. Keratoacanthomas enters, primary genitals, mouth, or 5. Subepidermal fibrosis anus 6. Epidermal cysts (5) Painless lymphadenopathy may occur b. Secondary (1) Follows resolution of the primary stage, symptoms become systemic Sexually Transmitted Diseases (STD) 219

(2) Localized or diffuse mucocutaneous 2. Serologic testing lesions (palms, soles [60–80%], mu- a. Nontreponemal—Venereal Disease Re- cous patches [21–58] and condyloma search Laboratory (VDRL), rapid plasma lata) with generalized lymphadenopa- reagin (RPR); 80–90% accurate in making thy along with flulike symptoms (low- a diagnosis grade fever, headache, sore throat, b. Treponemal—fluorescent treponemal an- malaise, arthralgias) tibody absorption test (FTA-ABS), T. pal- (3) May begin 4 to 6 weeks after appear- lidum particle agglutination (TP-PA) ance of primary lesion and resolve in 1 c. A positive RPR or VDRL must be con- week to 2 months firmed with a FTA-ABS or TP-PA c. Latent d. Nontreponemal test titers usually cor- (1) Begins after spontaneous resolution of relate with disease activity, and results secondary stage should be reported quantitatively; a four- (2) If no treatment, patient goes into early fold change in titer is equal to two dilu- latent phase for less than 1 year durations (e.g., 1:16 to 1:4 or 1:8 to 1:32) tion (asymptomatic) 3. Lumbar puncture—late or tertiary (3) Late latent phase (after 1 year 4. False positives for serologic testing (1%); duration) caused by viral infections, IV drug use, (4) May remain in this stage or progress pregnancy to tertiary stage 5. Tests for other STDs, consider HIV testing d. Tertiary (1) Characterized by gummas (nodular • Management/Treatment lesions) involving skin, mucous mem- 1. Who must be treated branes, skeletal system, and viscera a. Pregnant women (2) Cardiac symptoms, aortitis, aneu- b. Individuals with positive darkfield exami- rysm, or aortic regurgitation nation or positive treponemal antibody (3) Neurosyphilis may present without test symptoms or with tabes dorsalis, c. People treated previously who have a four- meningovascular syphilis, general pa- fold rise in quantitative nontreponemal ralysis, insanity, iritis, chorioretinitis, test and leukoplakia d. Patients with uncertain diagnosis (4) Not infectious e. Persons who were exposed within the 90 days preceding the diagnosis of primary, • Physical findings secondary, or early latent syphilis in a 1. Chancre on vulva, vagina, cervix, or at site of sexual partner—treat presumptively even entry of organism—begins primary stage if seronegative 2. Secondary stage manifestations may be gen- f. Persons who were exposed more than 90 eralized maculopapular rash, mucocutaneous days before the diagnosis of any stage of lesion, adenopathy syphilis in a sexual partner—treat pre- 3. Condyloma lata—wartlike lesions on vulva, sumptively if test results not immediately perianal region, and upper thighs available and opportunity for follow-up is 4. Tertiary may be manifested by multiple organ uncertain involvement 2. Treatment (CDC) 5. Gummas of vulva—tertiary manifestation; a. Primary or secondary appear as nodules that enlarge, ulcerate and (1) Benzathine penicillin G IM in a single become necrotic dose (2) Doxycycline orally bid for 2 weeks or • Differential diagnosis tetracycline orally qid for 2 weeks, for 1. Other genitoulcerative diseases; herpes, chan- penicillin allergic croid, lymphogranuloma venereum, granu- b. Latent loma inguinale (1) Early latent—Benzathine penicillin G 2. Genital carcinoma IM in a single dose 3. Trauma (2) Late latent or latent of unknown duration—Benzathine penicillin G given • Diagnostic tests/findings IM as three doses at 1-week intervals 1. Dark field microscopy of fluid from lesions re- c. Pregnancy—see Pregnancy chapter veals treponema d. HIV-positive individuals 220 Chapter 7 Gynecological Disorders

(1) May have a higher incidence of neu- 4. One week after onset, bilateral, tender, sup- rologic involvement and higher rate of purant inguinal lymphadenopathy (bubo) de- treatment failure—careful follow-up is velops (30–60%) important 5. Lesions resolve in 1 to 2 weeks if treated; 1 to 3 (2) Serologic test results may be atypical months if untreated (3) When clinical picture is positive and serologic test is negative, biopsy, dark • Physical findings field, or direct fluorescent antibody 1. Deep ulcerations with irregular, scalloped staining is done borders 3. Follow-up 2. Bilateral, tender, suppurant inguinal a. Quantitative nontreponemal serologic lymphadenopathy tests are repeated at 6, 12, and 24 months 3. Lesions found on labia, vagina, anogenital b. Titers should decline at least fourfold skin, and cervix within 12 to 24 months 4. May have foul odor c. A fourfold increase indicates inadequate treatment or a new infection • Differential diagnosis d. Pregnant women without a fourfold drop 1. Genital herpes in titer in a 3-month period, need repeat 2. Syphilis treatment 3. Malignancy of vulva e. Treponemal tests remain positive for lifetime 4. Trauma in most individuals regardless of treatment or 5. Donovanosis disease activity f. Report all cases to proper agency for follow-up • Diagnostic tests/findings of sexual contacts 1. Gram’s stain reveals gram-negative rods or chains Chancroid 2. Definitive test is culture to identify H. ducreyi—collect from lesion or bubo; difficult to • Definition—an acute, contagious, ulcerative, bac- isolate on culture; use specific medium (sensi- terial infection that is sexually transmitted tivity # 80%) 3. Clinical signs pathognomonic • Etiology/Incidence a. Genital ulcers with typical characteristics 1. Haemophilus ducreyi is a short, nonmotile, b. Regional lymphadenopathy gram-negative rod (anaerobe) that grows in c. Negative test for HSV chains known as “school of fish” pattern d. Suppurant inguinal adenopathy 2. Incubation period 4 to 5 days 4. Serologic testing for syphilis and HIV 3. Occurs only in a few areas of the US in discrete outbreaks; endemic in some areas • Management/Treatment 4. Most often seen in tropical and subtropical 1. Cured with treatment; may leave scarring in climates severe cases 5. Known cofactor is heterosexual transmission 2. CDC recommendations of HIV—strongly associated with increase in a. Azithromycin orally in a single dose incidence of HIV rates in the US and other b. Ceftriaxone IM in a single dose countries c. Ciprofloxacin orally for 3 days 6. 10% will be co-infected with syphilis and HSV d. Erythromycin base orally for 7 days 7. Recent increases in the US associated with 3. Ciprofloxacin is contraindicated for pregnant drug use, urban poverty, prostitution, and and lactating women and for persons younger those acquiring chancroid outside the US than 18 years 4. Follow-up—reexamine in 3 to 7 days; if ulcer- • Signs and symptoms ations have not improved reevaluate 1. May be asymptomatic 5. Management of sexual partners—if sexual 2. Papules or painful ulcerations on labia, ano- contact occurred during 10 days preceding on- genital skin, vagina, cervix in women; around set of patient’s symptoms, evaluate and treat the prepuce, frenulum, on coronal sulcus in men Lymphogranuloma Venereum (LGV) 3. May be foul odor • Definition—an ulcerative, bacterial, sexually transmitted disease Sexually Transmitted Diseases (STD) 221

• Etiology/Incidence a. Treat those who had sexual contact with 1. Caused by serotypes L1, L2, and L3 of Chla- the patient during the 30 days prior to on- mydia trachomatis; a bacterium; an obligate, set of symptoms intracellular parasite that infects columnar b. Evaluate for other STDs epithelium 2. Occurs infrequently in the US Pelvic Inflammatory Disease (PID) 3. Endemic in tropical areas and travelers to endemic areas • Definition—comprises a spectrum of inflam- 4. Incubation period 5 to 21 days or longer matory disorders of the upper female genital 5. Infects men more than women (5:1) tract, including any combination of salpingitis, endometritis, tubo-ovarian abscess, and pelvic • Signs and symptoms peritonitis 1. May be asymptomatic 2. May report painless ulcerations that may go • Etiology/Incidence unnoticed and heal within days (50%) 1. Causative organisms include Chlamydia tra- 3. Tender adenopathy usually occurs 1 to 4 weeks chomatis, Neisseria gonorrhea, polymicrobial after ulcer; may have fever, malaise, headache, infection (E coli, G. vaginalis, H. Influenzae, M. myalgia hominis) 2. One million cases are diagnosed annually • Physical findings 3. 200,000 hospitalizations at a cost of 5 billion 1. Painless ulceration on vulva at site of inocula- dollars tion; disappears in a few days 4. 25% of cases result in infertility, ectopic preg- 2. Tender inguinal and/or femoral lymphade- nancy, chronic pelvic pain, and are at risk for nopathy; most commonly unilateral major abdominal surgery 3. Rectal exposure in women or men who have 5. One-third of women with gonorrhea or sex with men (MSM) may result in proctocoli- chlamydia cervicitis will progress to PID if tis or inflammatory involvement of perirectal untreated or perianal lymphatic tissues resulting in fistu- 6. Teenagers account for one-fifth of total cases las and strictures 7. Risk factors a. Sexually active females less than 20 years • Differential diagnosis old 1. Inguinal or suppurant adenitis b. Multiple sexual partners 2. Chancroid c. Previous episode of PID 3. HSV d. Presence of chlamydia, gonorrhea, and/or 4. Syphilis bacterial vaginosis 5. Vulvar cancer e. Vaginal douching 8. Oral contraceptive pill use is protective • Diagnostic tests/findings 1. Aspiration and culture of material from fluc- • Signs and symptoms tuant lymph nodes—50% of cases will show 1. May be acute or mild chlamydia 2. Abdominal pain 2. Serologic testing—titer of more than 1:64 3. Vaginal discharge shows active disease 4. Fever 3. Complete blood count will show mild leukocy- 5. Dysuria tosis or monocytosis 6. Dyspareunia 4. Elevated sedimentation rate 7. Nausea/vomiting 5. Screening for other STDs 8. Vaginal spotting or bleeding (30%) 6. Encourage HIV screen • Physical findings • Management/Treatment 1. Lower abdominal tenderness, adnexal tender- 1. CDC recommends: ness, and cervical motion tenderness of vary- a. Doxycycline orally for 21 days ing degrees—minimum criteria for empiric b. Erythromycin base orally for 21 days treatment of PID in sexually active young 2. Follow-up—follow clinically until signs and women and other women at risk for STD with symptoms have resolved complaint of pelvic or lower abdominal pain 3. Management of sexual partner is presence of one or more of these three findings on pelvic examination 222 Chapter 7 Gynecological Disorders

2. Adnexal mass 6. Partner treatment—treat if contact occurred 3. Fever of more than 101°F (> 38.4°C) with patient during the 60 days prior to onset 4. Mucopurulent cervical or vaginal discharge of symptoms

• Differential diagnosis Â Urinary Tract Disorders 1. Ectopic pregnancy 2. Appendicitis Urinary Tract Infections (UTIs) 3. Ruptured ovarian cyst 4. Torsion of adnexal mass • Definition—a term that encompasses a broad 5. Ulcerative colitis range of clinical conditions affecting the urinary 6. Degenerative leiomyoma tract 7. Renal calculus 1. Cystitis—infection of the bladder 2. Urethritis—infection of the distal urethra • Diagnostic tests/findings 3. Acute pyelonephritis—infection of the kidney 1. Testing to provide laboratory documentation of cervical infection with C. trachomatis or • Etiology/Incidence N. gonorrhoeae 1. Escherichia coli most common organism 2. Sedimentation rate elevation and/or (80%), also Staphyloccous saprophyticus (15%), C-reactive protein Proteus mirabilis, Klebsiella pneumonia (all 3. Criteria for definitive diagnosis (in case of un- reside in the GI tract) sure diagnosis or poor response to treatment) 2. Colonization of bacteria in the vagina due to a. Histologic evidence of endometritis on alterations in pH increase the risk of bladder endometrial biopsy colonization b. Sonography or other radiographic tests 3. More common in women than men (ratio revealing tubo-ovarian abscess 1:8), with a 1–3% prevalence in nonpregnant c. Laparoscopy—abnormalities consistent women with PID 4. There are four major pathways of infection a. Ascending from urethra (> 90%) • Management/Treatment b. Hematogenous 1. Regimen A—ceftriaxone IM once plus doxy- c. Lymphatic cycline orally bid for 14 days, with or without d. Direct extension from another organ metronidazole orally bid for 14 days 5. Risk factors 2. Regimen B—cefoxitin IM once with a. Neurologic disease probenecid in a single dose plus doxycycline b. Renal failure orally bid for 14 days, with or without metro- c. Diabetes nidazole orally bid for 14 days d. Anatomic abnormalities 3. Regimen C—other third-generation cepha- e. Pregnancy losporin IM once plus doxycycline orally bid f. Stones for 14 days, with or without metronidazole g. Instrumentation orally bid for 14 days h. Poor success with medical regimen 4. Criteria for hospitalization i. Poor hygiene a. Patient is pregnant j. Infrequent voiding b. Pelvic abscess is suspected k. Diaphragm, tampon, and spermicide use c. When surgical emergency cannot be ruled l. Sexual activity—coital frequency, new out (ectopic pregnancy, appendicitis) sexual partner d. Severe illness, high fever, nausea and m. Immunosuppression vomiting n. Sickle cell disease or trait e. Failure of outpatient therapy o. Douching 5. Follow-up, reexamine within 72 hours—if not p. Catheterization significantly improved, review diagnosis and q. Estrogen deficiency treatment; may need hospitalization a. Criteria for improvement—defervescence, • Signs and symptoms reduction in direct or rebound abdominal 1. Range from mild to severe tenderness; reduction in adnexal, uterine, a. Acute cystitis and cervical motion tenderness (1) Abrupt onset b. Counsel on safer sexual practices (2) Dysuria (3) Frequency of urination Urinary Tract Disorders 223

(4) Urgency of urination b. Send urine for urinalysis and/or culture (5) Suprapubic pain and sensitivity if dipstick is negative in (6) Nocturia symptomatic woman (7) Painful bladder spasms 4. Test for vaginitis, and STD if indicated (8) Pyuria 5. Cystoscopy if indicated (9) Hematuria (gross) b. Pyelonephritis • Management/Treatment (1) Chills, fever 1. Uncomplicated UTI (2) Dysuria a. Treat even before tests results are available (3) Frequency of urination b. Use 3-day regimens—single dose treat- (4) Urgency of urination ment is less effective (5) Cloudy malodorous urine c. Suggested medical regimens for nonpreg- (6) Nausea, vomiting nant women: c. Urethritis (1) Nitrofurantoin orally (1) Gradual onset (2) Ciprofloxacin orally (2) Frequency of urination (3) Ofloxacin orally (3) Malodorous vaginal discharge (4) Norfloxacin orally (5) Sulfamethoxazole-trimethoprim • Physical findings orally 1. UTI presentation inconsistent 2. Recurrent infections—use above regimens for 2. Pyelonephritis 7 days a. Unilateral or bilateral costovertebral angle 3. Pyelonephritis—use above regimens for 10 tenderness days b. Fever 4. Recurrent infection—retest and retreat c. Flank or abdominal pain 5. Prevention/prophylaxis d. Vomiting a. Void after intercourse b. Discontinue use of spermicides and • Differential diagnosis diaphragm 1. Vaginitis c. Intravaginal estrogen in women with atro- 2. Sexually transmitted infection phy of genitalia 3. Fungal infections of urethra or bladder d. Avoid delay in emptying bladder 4. Interstitial cystitis 6. Referral 5. Infected calculus a. Patients with possible pyelonephritis 6. Fistula b. Patients who experience relapse after 7. Obstructive uropathy complete course of antibiotics 8. Tuberculosis of bladder c. Pregnant women 9. Malignancy d. Women with history of pyelonephritis 10. Side-effects of chemotherapy or radiation e. Chronic disease such as diabetes f. Suspected renal calculus, interstitial • Diagnostic tests/findings cystitis 1. Urine microscopy on clean catch—test shows g. Women who frequently use catheters more than 5 WBC per high-powered field (HPF) and the presence of bacteria with few Urinary Incontinence squamous cells 2. Urine culture and sensitivity • Definition—involuntary loss of urine a. Traditional criterion for infection—a colony count of more than 100,000 organisms • Etiology/Incidence per milliliter 1. Etiologies alone or in combination b. As few as 10,000 colonies have been a. Age-related genitourinary anatomic known to produce symptoms changes c. Evaluated for sensitivity to medications b. Medications, e.g., diuretics, antidepres- 3. Enzymatic (dipstick) testing—less reliable sants, antihistamines, sedatives (75% sensitivity) c. Nerve damage from stroke, demyelinating a. Indicates hematuria; nitrites indicate pres- disorders ence of bacteria; leukocyte esterase indi- d. Infections, tumors, diabetes, herniated cates presence of WBC disc 224 Chapter 7 Gynecological Disorders

e. Bladder neoplasm, fistulas, damage to 4. Postvoid residual measurement using catheter urogenital structures, atrophy (decrease in or scan estrogen) 5. Urinalysis/culture to evaluate for infection f. Restricted mobility, cognitive and func- 6. Cystometry, urethroscopy, and cystoscopy may tional impairment be useful g. Multiparity, obesity, smoking, constipa- 7. Urodynamic testing is confirmatory tion, family history in first-degree relative are risk factors • Management/Treatment h. Urge incontinence—most often associated 1. Transient incontinence can usually be treated with uninhibited detrusor contractions with identification and treatment of underly- 2. 10–25% of women between 15 and 64 years ing medical problems, behavior therapy such will suffer from incontinence as habit training and timed voiding 3. 50% of nursing home population experience 2. Stress incontinence—pelvic muscle exercises/ incontinence pelvic floor training with Kegel exercises and 4. Less than 50% of individuals seek help; most biofeedback, weight loss if obese, treatment are silent sufferers for constipation, pessaries 3. Urge incontinence—bladder retraining with • Signs and symptoms scheduled voiding, biofeedback, Kegel ex- 1. Stress incontinence ercises, avoiding bladder irritants, surgical a. Loss of urine, usually in small amounts, removal of obstruction, anticholinergic agents with coughing, laughing, sneezing (oxybutynin chloride, tolterodine tartrate) b. Vaginal dryness if atrophy present 4. Mixed incontinence—combine measures for 2. Urge incontinence urge and stress incontinence a. Involuntary loss of urine preceded by a 5. Surgery according to diagnosis sudden, strong urge to urinate 6. Referral to a urogynecologist b. Usually voids large amounts c. Difficulty in controlling once flow begins Â Breast Disorders d. Occurs without warning—cold weather, physical activity, laughing, sexual inter- Fibrocystic Breast Changes course, or placing a key in a door lock e. Patient will often complain of frequent • Definition—“nondisease” that includes nonprolif- voiding, urgency, nocturnal enuresis, erative microcysts, macrocysts, and fibrosis; and (10–30%)—overactive bladder proliferative changes such as hyperplasia and ad- 3. Mixed urinary incontinence—presents enosis; hyperplasia with atypia is associated with a with both symptoms of stress and urge moderate risk for breast cancer incontinence 1. Cystic changes—refers to dilatation of ducts; may regress with menses, may persist, or may • Physical findings disappear and reappear 1. Urinary leakage with increased abdominal 2. Fibrous change—mass develops following an pressure inflammatory response to ductal irritation 2. Relaxed pelvic floor muscles—cystocele 3. Hyperplasia—a layering of cells; has malignant 3. Vaginal atrophy, perineal irritation potential if atypical 4. Adenosis—related to changes in the acini in • Differential diagnosis the distal mammary lobule; ducts become sur- 1. Urinary tract infection rounded by a firm, hard, plaque like material 2. Prolapse of bladder 3. Tumor compressing bladder • Etiology/Incidence 4. Vaginal atrophy 1. Etiology not understood; occurs in response to 5. Stool impaction endogenous hormone stimulation, primarily estrogen • Diagnostic tests/findings 2. Conflicting studies on association with in- 1. Review prescription and nonprescription gestion of foods or beverages containing drugs for etiologic factors methylxanthines 2. Voiding diary 3. Most common benign breast condition in 3. Urinary stress test to assess loss of urine when women coughing and straining Breast Disorders 225

4. Palpable nodular changes observed in more f. Vitamin E to control breast pain (contro- than half of adult women 20 to 50 years of age; versial; no more than 50 to 600 IU a day) common ages 35 to 50 g. Mild analgesics; supportive brassiere 5. Detectable on radiography in 90% of women age 40 or older Fibroadenoma 6. Usually a regression of the signs after menopause • Definition—benign breast mass derived from fibrous and glandular tissue • Signs and symptoms 1. Breast pain and nodularity; usually bilateral • Etiology/Incidence 2. Frequently occurs or increases 1 to 2 weeks 1. Etiology unknown; development soon after before menses menarche—appears to be hormone related 3. May have clear or white nipple discharge 2. Most common benign, dominant mass in younger women • Physical findings 3. Occurs most often in women 15 to 25 years of 1. Multiple, usually cystic masses that are well- age defined, mobile, and often tender 4. Pregnancy may stimulate growth; may regress 2. Absence of breast skin changes with menopause 3. Most common sites—upper outer quadrant and axillary tail • Signs and symptoms 4. May have clear-to-white nipple discharge 1. Painless, single, rubbery mass 2. Round to lobular in shape • Differential diagnosis 3. May be from 2 to 4 cm in size to 15 cm tumors 1. Carcinoma 4. No nipple discharge 2. Galactorrhea 5. Does not change with menstrual cycle 3. Mastitis 4. Costochondritis • Physical findings 1. Firm, well delineated, freely movable, rubbery, • Diagnostic tests/findings round, nontender mass; usually unilateral 1. Mammography to identify and characterize 2. No nipple discharge masses 2. Ultrasound to determine if mass is cystic • Differential diagnosis 3. Fine needle aspiration (FNA) if dominant 1. Carcinoma of the breast mass; cytologic evaluation 2. Cystosarcoma phyllodes 4. Biopsy or excision if dominant mass or follow- 3. Benign cyst ing findings are present: a. Bloody fluid on aspiration • Diagnostic tests/findings b. Failure of mass to disappear after 1. Fine needle aspiration (FNA) to determine aspiration whether cystic or solid c. Recurrence of a cyst after two aspirations 2. Excisional biopsy d. Solid mass not diagnosed as fibroma 3. Ultrasonography and/or mammography will e. Bloody nipple discharge help distinguish singular from multiple non- f. Nipple ulceration; presence of skin edema palpable masses (ultrasound best choice for or erythema young women)

• Management/Treatment • Management/Treatment 1. Treatment not necessary 1. Observation, if diagnosis is confirmed and 2. Aspiration of palpable cysts may be curative younger than 25 years 3. Patients with symptomatic nodularity or with 2. May be removed to alleviate patient anxiety or mastalgia are best treated medically if diagnosis is uncertain a. Oral contraceptive pills; good first choice 3. Follow-up with monthly self-breast examina- (improvement seen in 70–90% of women) tions and annual breast examination by clini- b. Danazol cian; annual mammograms if criteria of age c. Tamoxifen and risk factors met d. Bromocriptine 4. Key points e. Restriction of methylxanthines (caffeine, tea, cola, chocolate) 226 Chapter 7 Gynecological Disorders

a. No mass is obviously benign—each Breast Carcinoma should be carefully evaluated to rule out carcinoma • Definition—malignant neoplasm of the breast b. Nipple discharge is seldom associated with carcinoma of the breast; when there • Etiology/Incidence is spontaneous clear, serous or bloody 1. Possible interaction of ovarian estrogen and discharge or postmenopausal discharge nonovarian estrogen; estrogen of exogenous present cancer should be ruled out with a origin with susceptible breast tissue thorough evaluation 2. Most common female malignancy—second to c. Breast discomfort is usually associated lung cancer as leading cause of cancer-related with fibrocystic changes death; incidence is steadily increasing in US 3. Incidence increases with age (75% are > 40 Intraductal Papilloma years of age) 4. Cumulative lifetime risk is 10.2% or 1 in 9; in- • Definition—benign lesion of the lactiferous duct, crease in numbers may indicate better detec- most common in the perimenopausal age group tion and larger numbers of women in their 40s and 50s • Etiology/Incidence 5. Risk factors 1. Proliferation and overgrowth of epithelial tis- a. Women with BRCA1 and BRCA2 sue of the subareolar collection duct b. Advancing age 2. Occurs in the perimenopause, or menopausal c. Mother and/or sister with breast cancer woman 40 to 59 years of age d. Previous breast cancer 3. Most common cause of pathologic nipple e. Perimenopausal status discharge f. Previous endometrial or colon cancer g. Previous breast biopsy with atypical hy- • Signs and symptoms perplasia, lobular neoplasm 1. Bloody, serous, or turbid discharge (not h. Menarche before age 12; menopause after milk)—which may occur spontaneously age 55 2. Mass not usually palpable i. Nulliparity, first pregnancy after 30 3. Feeling of fullness or pain beneath areola j. Hormone replacement therapy, oral con- (possible) traceptive pills (questionable) k. Obesity, environmental factors; exposure • Physical findings to radiation or pesticides 1. Expression of serosanguineous nipple dis- l. Heavy alcohol use; fat in diet charge from a single duct when pressure applied to affected duct • Signs and symptoms 2. Poorly delineated, soft mass may be palpated 1. Breast mass—most often upper-outer 3. Papilloma are usually singular quadrant 2. May have spontaneous clear, serous, or bloody • Differential diagnosis nipple discharge 1. Intraductal carcinoma 3. May have retraction, dimpling, skin edema, 2. Multiple papillomatosis erythema 3. Galactorrhea 4. Axillary, supraclavicular, or infraclavicular lymphadenopathy may be present • Diagnostic tests/findings 1. Microscopy of breast fluid to visualize fat • Physical findings globules 1. Mass fixed, poorly defined, irregular, usually 2. Cytology of fluid—false negative rates of 20% nontender; palpable at 1 cm for cancer 2. May have nipple discharge, irritation, retrac- 3. Mammography tion, edema 4. Radiologic ductogram—use is controversial 3. Enlarged lymph nodes 5. Excisional biopsy of duct • Differential diagnosis • Management 1. Fibroadenoma 1. Refer for surgical excision 2. Fibrocystic breast changes 2. Excisional biopsy is curative 3. Trauma 4. Mastitis Congenital and Chromosomal Abnormalities 227

• Diagnostic tests/findings c. Incomplete canalization (atresia); e.g., im- 1. Mammogram detects 30–50% of cancers perforate hymen, cervical atresia 2. Ultrasound to distinguish solid from cystic d. One-third have urinary tract abnormali- mass ties, e.g., ectopic kidney, renal agenesis, 3. Histology for definitive diagnosis—specimen horseshoe shaped kidney, abnormal col- obtained through open biopsy, needle biopsy, lecting ducts fine needle aspiration (FNA), or stereotactic 2. Ovaries may be developed, resulting in well- core needle biopsy developed secondary sexual characteristics 4. CT scan of liver, lungs, bone to rule out metastasis • Differential diagnosis 5. Presence of estrogen receptors determined by 1. Various congenital anomalies assay 2. Anomalies of urinary tract 6. Sentinel node biopsy 3. Primary amenorrhea 7. Negative mammogram and negative aspiration cytology does not exclude malignancy • Diagnostic tests/findings 1. Structural abnormalities detected by ultra- • Management/Treatment sonography, MRI, hysterosalpingogram, 1. Referral to oncologist if malignancy is sus- laparoscopy pected; staging will determine appropriate 2. Chromosomal abnormalities ruled out with treatment options karyotyping (46XX) 2. Early breast cancer—surgery or surgery and radiation; 60–70% choose lumpectomy, axil- • Management/Treatment lary node dissection, and breast radiation 1. Referral to reproductive endocrinologist 3. Medical therapy for hormone receptor positive 2. Surgical intervention tumors—tamoxifen, aromatase inhibitors 4. Radiotherapy and cytotoxic chemotherapy are Androgen Insensitivity/Resistance adjuvant therapy in late disease Syndrome

Â Congenital and Chromosomal • Definition—genetically transmitted androgen re- Abnormalities ceptor defect; individual is genotypic male (46XY) but phenotypic female; previously called testicular Müllerian Abnormalities feminization

• Definition—congenital anomalies involving the • Etiology/Incidence uterus, fallopian tubes, and upper vagina resulting 1. Individual has testes and a 46XY karyotype from absence of antimüllerian hormone (AMH) 2. Transmitted by maternal X-linked recessive gene; a defect in androgen receptors; 25% risk • Etiology/Incidence of affected child, 25% risk of carrier 1. Possible causes include teratogenesis, genetic 3. Third most common cause of primary amen- inheritance, and multifactorial expression orrhea; represents 10% of all cases 2. Occurs in up to 15% of women with recurrent 4. Risk of malignant transformation of gonads spontaneous abortion and in 5–19% of infertile (5%); incidence of malignancy is rare before women puberty

• Signs and symptoms • Signs and symptoms 1. History of pregnancy loss or infertility 1. Often not detected until puberty 2. Amenorrhea, dysmenorrhea 2. Primary amenorrhea 3. Dyspareunia 3. Infertility

• Physical findings • Physical findings 1. Many variations may occur 1. Uterus and ovaries are absent and a blind a. Lack of development (agenesis); e.g., no pouch vagina is present; labia underdevel- vagina, uterus, tubes, uterine cavity oped; absent or scant pubic hair b. Incomplete development (hypoplasia); 2. Normally developed breast with small nipples e.g., partial vagina, bicornate uterus, par- and pale areola tial uterine cavity 228 Chapter 7 Gynecological Disorders

3. Inguinal hernias (50%) or labial masses in formation), Addison’s disease (adrenal in- infant child due to partially descended testes; sufficiency), alopecia, and vitiligo testes may be intra-abdominal d. Hearing loss 4. Scant body hair e. Normal intelligence; may have difficulty 5. Growth and development are normal; overall with mathematical ability, visual–motor height usually greater than average coordination, and spatial–temporal 6. May have horseshoe kidneys processing

• Differential diagnosis • Physical findings 1. Müllerian anomalies (agenesis) 1. No secondary sex characteristics 2. Incomplete androgen insensitivity 2. Uterus present; absent or streak ovaries; infertile • Diagnostic tests/findings 3. Congenital anomalies as described under 1. Karyotype reveals 46XY; phenotype normal signs and symptoms female 4. Renal (horseshoe kidney) and cardiac anoma- 2. Testosterone greater than 3ng/mL and LH lev- lies (coarctation of aorta, bicuspid aortic els normal to slightly elevated valves, mitral valve prolapse, aortic aneurysm) 5. Hearing loss • Management/Treatment 6. Hypothyroidism, adrenal insufficiency 1. Once full development is attained (after pu- 7. Alopecia, vitiligo berty), gonads should be removed at about age 16 to 18 • Differential diagnosis—other forms of gonadal 2. Estrogen replacement therapy after gonads dysgenesis removed 3. Evaluate other family members; sensitive • Diagnostic tests/findings counseling 1. FSH—if elevated need karyotype determination Turner’s Syndrome 2. Ultrasonography or MRI scan 3. Renal ultrasonography, cardiology • Definition—gonadal dysgenesis; an abnormality consultation in, or an absence of one of the X chromosomes; phenotypically female; described by Turner in 1938 • Management/Treatment 1. Recognition of multisystem involvement and • Etiology/Incidence involvement of multiple medical specialists 1. Usually a deficiency of paternal contribu- 2. Refer to endocrinologist tion of sex chromosomes reflecting paternal 3. Estrogen and progesterone replacement nondisjunction 4. Human growth hormone 2. Occurs in 1 out of 2500 to 5000 liveborn girls 5. Participation in a genetic support group 3. Most common chromosomal abnormality found on spontaneous abortuses (45X) Â Additional Gynecological 4. 60% of Turner’s patients have a total loss Disorders of one X chromosome; 40% are mosaics or have structural aberrations in the X or Y Chronic Pelvic Pain chromosome • Definition—a nonspecific term associated with ac- • Signs and symptoms tual or potential tissue damage; noncyclic or cyclic 1. Turner phenotype recognizable at any time of pelvic pain that lasts longer than 6 months, is not development relieved by nonnarcotic analgesics, and is of suffi- a. Short stature, webbed neck, shield chest cient severity to cause functional disability and/or with widely spaced nipples, increased car- lead to seeking medical care rying angle of elbow, arched palate, low neck hairline, short fourth metacarpal • Etiology/Incidence bones, disproportionately short legs, lack 1. Gynecological, orthopedic, gastrointestinal, of breast development, scant pubic hair urologic, neurologic, and psychosomatic b. Amenorrhea; lack of sexual development origin c. Autoimmune disorders; Hashimotos’s thy- 2. Relationship between pelvic pain and the roiditis (hypothyroidism [10%] with goiter underlying gynecological pathology is often inexplicable Additional Gynecological Disorders 229

3. Gynecological causes • Diagnostic tests/findings a. Endometritis 1. Laboratory studies are of little value in the di- b. Salpingo-oophoritis (PID) agnosis of chronic pelvic pain c. Adhesions 2. Pregnancy test, CBC, erythrocyte sedimenta- d. Pelvic congestion syndrome tion rate (ESR), urinalysis e. Ovarian remnant syndrome 3. Pelvic ultrasonography, hysteroscopy f. Myomata uteri 4. If bowel or urinary symptoms; barium enema, g. Endometriosis upper GI series, IV pyelogram h. Adenomyosis 5. If musculoskeletal disease suspected; i. Gynecological malignancies (especially lumbosacral radiography and orthopedic late stage) consultation 4. 48% associated with prior psychosexual 6. Diagnostic laparoscopy—ultimate method of trauma, including molestation, incest, and diagnosis rape 5. Accounts for up to 10% of gynecological con- • Management/Treatment sultations, 10% of laparoscopies and 12% of 1. Appropriate referral for treatment of organic hysterectomies in the US, costing $2 billion pathology annually 2. Referral for psychiatric evaluation if no physi- 6. Mean age is 28.6 cal causes found; counseling for prior sexual 7. 20% have coexistent psychological pathology trauma or domestic violence 8. No significant differences by race, education, 3. May need both medical and psychological mean age of menarche, menstrual cycle, or management gravidity and parity 4. Supplemental therapies may include biofeed- 9. Diagnosis is difficult and patients are often back, acupuncture, transcutaneous nerve referred to many specialists while becoming stimulation (TENS) frustrated, angry, and/or defensive Pelvic Relaxation • Signs and symptoms 1. Paroxysms of sharp, stabbing, sometimes • Definition—a nonspecific term denoting a condi- crampy, or dull continuous pain, usually tion occurring chiefly as weakness and defect in severe pelvic supporting tissues that includes: 2. Dysmenorrhea, dysuria, or vaginal pain 1. Cystocele—herniation of the bladder into the 3. Pain may or may not be reproducible by vaginal lumen manipulation of pelvic organs on bimanual 2. Urethrocele—herniation of the urethra into examination the vagina 3. Cystourethrocele—both urethra and bladder • Physical findings are herniated 1. Physical and gynecological examination may 4. Rectocele—bulging or herniation of the ante- be normal rior rectal wall and posterior vaginal wall into 2. Findings consistent with specific medical, or- the opening of the vagina thopedic, neurologic, gastrointestinal disorder 5. Enterocele—a portion of the large or small in- 3. Findings consistent with specific gynecologi- testine herniates into the upper vagina or dis- cal disorder sects into the rectovaginal space 6. Vaginal prolapse—loss of support of the • Differential diagnosis vaginal apex resulting in eversion toward the 1. Pregnancy, ectopic, spontaneous abortion, introitus trophoblastic disease 7. Uterine prolapse—descent of the uterus and 2. Gynecological disease—endometriosis, PID, cervix into the vagina toward the introitus cancer or torsion of ovaries, rupture of ovarian cyst • Etiology/Incidence 3. Nongynecological disease—renal calculi, ir- 1. Weakness in supporting structures include ritable bowel, appendicitis, urinary tract dis- the pelvic diaphragm, ligaments, and fascia— eases including interstitial cystitis, orthopedic, commonly related to neuromuscular injury at neurologic, gastrointestinal disorders childbirth, resulting in denervation injury of muscular floor 230 Chapter 7 Gynecological Disorders

2. Other causes include conditions that cause 2. Occurs most often in Caucasian women under chronic increase in abdominal pressure— 30 years of age using tampons during men- obesity, straining, chronic lung disease struation; rarely associated with other articles (coughing); nerve function altered by diabe- placed in the vagina, such as diaphragms, tes, pelvic surgery, neurologic disorders, and sponges, and cervical caps hypoestrogenism 3. Incidence is 1 to 2 per 100,000 per year in women using tampons • Signs and symptoms 4. 10% of population lacks sufficient antitoxin 1. May be asymptomatic and discovered during antibodies to S. aureus routine examination 5. Nonmenstruating associated cases (55%) are 2. Pelvic, vaginal, and low back pain and pressure caused by puerperal sepsis, post-Cesarean 3. Bulging or mass in vagina; difficulty in walking endometritis, mastitis, PID, wound infection, 4. Urinary incontinence, incomplete bladder insects emptying, difficulty in evacuation of feces 5. Exposed vagina may become dry and ulcer- • Signs and symptoms ated; purulent discharge 1. Sudden onset fever, 102°F or greater 2. Diffuse macular sunburn-like rash over face, • Physical findings trunk, and extremities that desquamates 1 to 2 1. Descent of the anterior or posterior vaginal weeks after onset walls; various degrees of descent of the cervix 3. Hyperemia of conjunctiva, oropharynx, into the vagina indicating uterine prolapse tongue, vagina 2. Poor muscle strength in pubococcygeal 4. GI symptoms—nausea, vomiting, diarrhea, muscles abdominal tenderness, dysphagia 3. Complete prolapse of uterus (prodentia); ul- 5. Genitourinary—vaginal discharge, adnexal ceration, purulent discharge, bleeding tenderness 6. Flulike symptoms—headache, sore throat, my- • Differential diagnosis algia, rigors, photophobia, arthralgia 1. Tumors of pelvis or abdomen involving any 7. Cardiorespiratory—symptoms of pulmonary abdominal structure edema, disseminated intravascular coagula- 2. Diverticulum of urethra tion (DIC), endocarditis, acute respiratory distress syndrome (ARDS) • Diagnostic tests/findings 8. Organ failure symptoms—renal, hepatic 1. Rule out tumors with appropriate evaluation as indicated • Physical findings 2. Valsalva to assess full extent of prolapse 1. Fever 2. Diffuse macular erythematous rash and • Management/Treatment desquamation 1. Nonsurgical treatment—usually pessary 3. Hyperemia of conjunctiva, oropharynx, 2. Surgical treatment to correct vaginal anatomy tongue, vagina (if severe) 4. Orthostatic hypotension 3. Kegel exercise to help improve muscle tone 5. Abdominal tenderness 4. To avoid straining with bowel movements— 6 Vaginal discharge, adnexal tenderness use of stool softeners, dietary intervention, 7. Physical signs of pulmonary edema, dissemi- e.g., increase fluid intake, raw fruits and veg- nated intravascular coagulation, endocarditis, etables with skin, dried fruits, high fiber break- acute respiratory distress syndrome (ARDS) fast foods 8. Altered sensorium 5. Use of biofeedback modalities • Differential diagnosis Toxic Shock Syndrome 1. Septic shock 2. Rocky Mountain spotted fever • Definition—rare, potentially fatal, febrile condition 3. Scarlet fever affecting multiple systems 4. Staph food poisoning 5. Meningococcemia (meningitis) • Etiology/Incidence 6. Legionnaires’s disease 1. Associated with toxins produced by strains of 7. PID Staphylococcus aureus Additional Gynecological Disorders 231

• Diagnostic tests/findings 7. 25% of male offspring may be affected with 1. Cultures to determine source of infection, e.g., cryptorchidism, small testes, epididymal cysts throat, vagina, cervix, blood 2. Serologic tests to rule out Rocky Mountain • Signs and symptoms spotted fever, syphilis, rubeola 1. May have discharge, postcoital bleeding, 3. Urinalysis dyspareunia 4. Evaluation for presence of multiorgan involve- 2. May report infertility; poor pregnancy ment—serum multichemical analysis, clot- outcomes ting profile, blood gases, CBC with differential (platelets # 100,000/mm3) • Physical findings 5. Diagnostic criteria includes involvement of 1. Vaginal adenosis (most common) three or more organs or systems that include— 2. Nodularity of cervix or vagina cardiopulmonary, CNS, hematologic, liver, 3. Visible cervical abnormalities, e.g., ridges, renal, mucous membranes, musculoskeletal, cockscomb, collar, hood on anterior cervix; gastrointestinal pseudopolyps, hypoplasia 4. Colposcopically resembles dysplasia; mosaic • Management/Treatment pattern, punctation 1. Refer immediately to hospital for emergency 5. Transverse or longitudinal vaginal septum treatment in intensive care setting 6. Uterine abnormalities; T-shaped uterus, bicor- 2. Prevention nate or didelphis uterus, septate uterus a. Avoidance of tampons or leave in place no longer than 4 hours; alternate with pads • Differential diagnosis b. Educate regarding signs and symptoms 1. Congenital anomalies and prompt treatment 2. Genetic disorders c. History of TSS—avoid tampons, cervical caps, diaphragms • Diagnostic tests/findings 1. Pap test of squamocolumnar junction to rule Diethylstilbestrol (DES) in Utero out cancer 2. Colposcopy and biopsy of suspicious areas • Definition—a synthetic nonsteroidal estrogen ap- 3. Hysterosalpingogram or ultrasonography to proved by the FDA in 1942 to prevent abortion; evaluate structural anomalies prescribed for an estimated 2 million pregnant women for the purpose of preventing fetal wast- • Management/Treatment age; did not prove to be effective; FDA withdrew 1. No current therapy approval for use in 1971 2. Follow annually with Pap test/colposcopy 3. Thorough palpation of vagina, cervix, and • Etiology/Incidence vaginal wall for masses 1. Vagina originally lined with columnar epi- 4. Refer if abnormality suspected thelium, which is eventually replaced with squamous epithelium; if DES is introduced Vulvar Dermatoses that transformation is not completed; one- third of exposed patients will have columnar • Definition—nonneoplastic disorders of vulvar epi- epithelium in the vagina (adenosis) thelium growth and nutrition producing a number 2. Structural changes of the cervix and vagina of gross changes; three major vulvar dermatoses: occur in 25% of females exposed in utero to lichens sclerosus; lichens planus (other names DES; transverse vaginal septum, cervical col- include erosive lichens planus, erosive vaginitis, lar, uterine constriction band desquamative vaginitis); lichens simplex chroni- 3. Occurrence of these abnormalities is related to cus, (previously known as “nonneoplastic epithe- the dose of medication and the first time ex- lial disorders”); may be seen on other parts of the posed; risk is significant if administration was body begun after the 18th week of gestation 4. Increased incidence of preterm delivery, spon- • Etiology/Incidence taneous abortion, and ectopic pregnancy 1. Lichen sclerosus, lichen planus—etiology 5. Clear cell carcinoma of the vagina occurs unknown; perianal involvement in 50% of rarely, a 1/1000 risk patients, less than 20% have lesions on trunk; 6. Columnar epithelium of vagina is especially may be familial incidence and links with susceptible to HPV 232 Chapter 7 Gynecological Disorders

certain histocompatibililty antigens (HLA) 4. Sometimes, autoimmune diseases are subtypes and autoimmune disease associated with lichen sclerosus and li- 2. Lichen simplex chronicus—thickening of skin chen planus—vitiligo, alopecia areata, in response to chronic rubbing or scratching; ulcerative colitis, myasthenia gravis, and more common in people with hay fever or hypogammaglobulinemia chronic inflammation; chronic candida often 5. Lichen simplex chronicus the initiating factor a. Thickened, leathery, lichenified plaques 3. Can occur at any age from early childhood to on labia majora old age b. Other locations—nape of neck, ankle, forearm, antecubital and popliteal fossae; • Signs and symptoms hair and scalp (excoriated papules) 1. Lichen sclerosus c. Pruritus especially with stress; scratching a. Skin easily traumatized; bruises and pur- is sometimes violent, patient stops only pura common; blisters, ulceration when skin becomes eroded and painful b. Severe itching and burning; lesions do not correlate with discomfort • Differential diagnosis c. Skin of vulva thin and wrinkled 1. Vitiligo d. Obliteration of clitoris 2. Vulvar carcinoma 2. Lichen planus 3. Seborrheic dermatitis a. May affect gingival and oral mucosa 4. Psoriasis b. Untreated may cause vaginal adhesions 5. Tinea c. Flares and remits spontaneously 6. Vaginitis d. Secondary infection may occur 7. Sexually transmitted infection 3. Lichen simplex chronicus 8. Parasitic infection a. Can appear on any body surface b. Severe itching • Diagnostic tests/findings c. Thickening of vulvar skin 1. Colposcopy 2. Biopsy is the gold standard for diagnosis • Physical findings 3. Saline and KOH wet mount to rule out 1. May be found on other parts of the body vaginitis 2. Lichen sclerosus 4. STD testing if indicated a. Loss of pigmentation, symmetry of distribution, and loss of vulvar architecture • Management/Treatment with obliteration of the clitoris 1. Lichen simplex chronicus—antifungal cream b. Thickened dermis; white, thin, wrinkled as directed (terconazole first choice) and scaly 2. Superpotent topical steroids found to be best c. Bruises or purpura, blisters, ulcers treatment for vulvar dermatoses that have d. Does not affect the vagina thickened skin; clobetasol e. Confetti pattern of small dots can be 3. Apply sparingly confluent 4. Treatment may not be necessary in the ab- 3. Lichen planus sence of active disease—flares require initia- a. Shiny, smooth, flat topped papules, tion of topical steroid with a tapering regimen plaques on the skin and white patches of 5. High-potency steroids should not be used erosions on mucous membranes; may be for long periods of time (cause thinning of widespread on vaginal mucosa the skin and “rebound” dermatitis when b. Papules are purplish and range from pin- discontinued) point size to more than 1 cm in diameter; 6. Should not be used when change in skin tex- may scatter, coalesce into plaques, or ture or thickness is absent become annular or linear along scars or 7. Skin redness alone should not be treated with scratch marks anything more potent than 1% hydrocortisone c. May be found on wrists, shins and buccal cream mucosa; occasional scarring and alopecia 8. Testosterone ointment of no value on scalp; nails—ridging, nail loss 9. Advise gentle soaps and cotton underwear d. Superficial vaginal adhesions 10. Long-term/chronic conditions require pa- e. Flares and remits spontaneously—lasts tience on part of clinician and patient; coun- from weeks to several years seling may be necessary; no overnight cure Additional Gynecological Disorders 233

11. May try Burow’s solution soaks for relief of lo- • Etiology/Incidence cal irritation 1. Constant pain usually means neurologic dysfunction of some kind (pudendal neuralgia, Vestibulitis dyesethetic vulvodynia, “essential” vulvodynia, peripheral neuropathy, chronic local pain syn- • Definition—marked inflammation of the minor drome (CLPS), and others) vestibular glands; reasons unclear 2. May be related to urethral syndrome or interstitial cystitis • Etiology/Incidence—may be bacterial, fungal, or viral agents; or unknown etiology • Signs and symptoms 1. Severe burning, stinging, irritation or • Signs and symptoms “rawness” 1. Introital discomfort and dyspareunia of vary- 2. No visible dermatoses or intermittent ing degrees; may be severe and incapacitating; symptoms dysuria 3. Two major presentations 2. Pain described as burning (most common) a. Constant pain b. Pain with intercourse (dyspareunia) • Physical findings 1. Gross examination may be unremarkable • Physical findings—no visible lesions or dermatoses 2. Colposcopy or careful examination with a magnifying glass reveals tiny erythematous • Differential diagnosis foci with mild edema around gland openings 1. Vaginal infection 3. Hymen constricted, firm, and tender to 2. Allergy/sensitivity palpation 3. Psychogenic disorder—history of sexual abuse, rape, incest • Differential diagnosis 1. Vaginitis • Diagnostic tests/findings 2. Sexually transmitted infection 1. Colposcopy/biopsy to rule out dermatoses, 3. Lichen planus, sclerosus,or simplex chronicus pathology 4. Contact dermatitis 2. Testing to evaluate bladder—infection or other 5. Trauma pathology 3. Evaluate vaginal secretions as indicated • Diagnostic tests/findings 1. Colposcopy reveals classic inflammation of • Management/Treatment gland openings 1. Treat infections as appropriate 2. Pain can be reproduced by vestibule contact 2. Amitriptyline, gabapentin, and/or clonazepam with a cotton-tipped applicator often helpful 3. Wet mount and saline microscopic assessment; rule out vaginitis Infertility 4. Testing for STD as indicated • Definition—inability to conceive after 1 year of un- • Management/Treatment protected coitus 1. Treat inflammation if cause is determined; frequently candidiasis • Etiology/Incidence 2. Gabapentin or amitriptyline 1. Ovulatory dysfunction (15%)—poorly recep- 3. Surgery (laser) or excision may be useful; fre- tive cervical mucus due to estrogen levels, quent recurrences polycystic ovarian syndrome (PCOS), primary 4. Counseling or psychological support includ- ovarian failure ing antidepressants are useful to assist with 2. Tubal and pelvic pathology (35–40%)—fi- chronic pain broids, neoplasm, congenital anomalies, sal- 5. Expect long-term chronic therapy pingitis, adhesions, endometritis, cervicitis, endometriosis Vulvodynia 3. Male factor (35–40%) a. Abnormal semen analysis, oligospermia, • Definition—chronic vulvar discomfort, especially abnormal sperm penetration and sperm burning sensation antibodies 234 Chapter 7 Gynecological Disorders

b. Sperm exposure to heat, radiation, envi- (5) Sperm evaluation for normal ronmental toxins characteristics c. Coital frequency, cannabis, cocaine, DES 4. Basal body temperature exposure a. Basal body temperature detects increase d. Anatomical abnormalities such as hypo- in body temperature in response to pro- spadias, retrograde ejaculation (obstruc- gesterone; indicates ovulation/ tion), varicocele anovulation; times ovulation for purpose 4. Aging women—increased incidence when oo- of conception/contraception cytes are of advanced age b. Procedure 5. Cigarette and cannabis smoking (inhibits (1) Temperature reading each morn- GnRH); greatest risk with smoking at an early ing prior to arising/drinking/eating/ age activity 6. Thyroid disease (2) Recorded on graph 7. Diethlystilbestrol exposure; also increases fetal (3) Normal value in follicular phase less wastage than or equal to 98°F 8. Infrequent intercourse; possible sexual (4) Rises in luteal phase 0.4° to 0.6°F dysfunction (5) Increase maintained until the next menses begins • Signs and symptoms—none specifically (6) This sustained increase indicates biphasic/ovulatory cycle • Physical findings—none specifically 5. Ovulation prediction testing a. Urine test for LH • Differential diagnosis—none b. Predicts ovulation within 24 to 26 hours

• Diagnostic tests/findings • Management/Treatment 1. Hysterosalpingogram 1. Female factors, ovulatory dysfunction—ovula- a. Fluoroscopic radiography of the uterus tion induction therapy and fallopian tubes to determine tubal pa- 2. Luteal phase defect—progesterone tency and intrauterine/fallopian tube ab- 3. Infections/endometriosis—appropriate normalities; used to evaluate patients with therapy history of infertility, spontaneous abor- 4. Tubal occlusion/obstruction—surgery tion, preterm delivery; contraindicated in 5. Male factor—antisperm antibodies treated by patients allergic to radiopaque dye, preg- washing sperm or immunosuppressive drug nant, or with abnormal bleeding therapy, varicocele repair, vasectomy reversal b. Dye is instilled in the uterus through (50–60% success rate), nonreversible proce- the cervix; it then spreads through fal- dures require assisted reproductive technology lopian tubes; followed by radiographic 6. Assisted reproductive technology (ART)—all assessment the techniques used to achieve pregnancy that 2. Hysteroscopy involve direct retrieval of oocytes from the a. Minor operative procedure allows for in- ovary spection of endocervix and endometrial a. In vitro fertilization (IVF)—oocytes are cavity; useful in the evaluation of infertil- extracted, fertilized in the laboratory, then ity, abnormal bleeding, and endometrial transferred through the cervix into the cancer uterus (most common procedure, success b. Under anesthesia, lighted hysteroscope is rate (15–20%) inserted through the cervix into the uter- b. Gamete intrafallopian transfer (GIFT)— ine cavity placement of oocytes into the fallopian 3. Postcoital testing (Huhner’s test) tube (25% success rate) a. Microscopic evaluation of sperm count c. Zygote intrafallopian transfer (ZIFT)— and variability in cervical mucus following placement of fertilized oocytes into the intercourse fallopian tube (18–20% successful) b. Instructions d. Tubal embryo transfer (TET)—placement (1) No intercourse 48 hours prior to test of cleaving embryos into the fallopian (2) Intercourse during frame of ovulation tubes (not often used) (3) Evaluation within 6 to 24 hours e. Peritoneal oocyte and sperm transfer (4) Specimen of mucus collected from (POST)—placement of oocytes and sperm cervix Additional Gynecological Disorders 235

in the pelvic cavity (play minimal role in (a) Reactive cellular changes associ- treatment) ated with inflammation, radia- f. Subzonal insertion of sperm by microin- tion, intrauterine device jection (SUZI)—used for male factor (b) Glandular cells status 7. Sensitive counseling; infertility support groups posthysterectomy (c) Atrophy Abnormal Pap Test c. Epithelial cell abnormalities (1) Squamous cell abnormalities • Definition—collection and microscopic evaluation (a) Atypical squamous cells of unde- of epithelial cells of the cervix and endocervix sug- termined significance (ASC-US) gestive of future cervical cancer; results may range (b) Atypical squamous cells cannot in degree from normal to atypical, mild, moderate, exclude HSIL (ASC-H) and severe abnormalities to invasive cancer (c) Low-grade squamous intraepithelial lesion (LSIL); encompasses • Abnormalities may be reported in one or more of human papillomavirus/mild three synonymous terms dysplasia/cervical intraepithelial 1. Cervical dysplasia neoplasia 1(CIN 1) 2. Cervical intraepithelial neoplasia (CIN) (d) High-grade squamous intra- 3. Squamous intraepithelial lesion (SIL) epithelial lesion (HSIL); encom- 4. The most common nomenclature in use today passes moderate dysplasia/ is the Bethesda System (1988, revised 1991 and carcinoma in situ/ CIN 2 and 2001) CIN 3 (e) Squamous cell carcinoma • The 2001 Bethesda System for reporting results of (2) Glandular cell abnormalities cervical cytology includes (a) Atypical glandular cells (AGC) 1. Specimen adequacy specified as endocervical, endo- a. Satisfactory for evaluation; will note metrial or glandular cells presence/absence of endocervical/ (b) Atypical glandular cells, favor transformation zone component neoplastic some features of neo- b. Unsatisfactory for evaluation—specimen plasm but not sufficient to reach obscured by blood or inflammation, interpretation of adenocarcinoma inadequate number of squamous cells, in situ air dried slide, not processed because (c) Endocervical adenocarcinoma in unlabeled situ (AIS) 2. Interpretation/Results d. Other—endometrial cells in women 40 a. General categorization years of age or older (1) Negative for intraepitheal lesion or malignancy • Management/Treatment (2) Epithelial cell abnormality 1. Specimen adequacy (3) Other a. Satisfactory for evaluation—no action b. Negative for intraepithelial lesion or needed malignancy b. Unsatisfactory for evaluation—assess and (1) No epithelial abnormality treat as needed if inflammation is cause; (2) Will report presence of organisms repeat Pap test in 4–6 months; may defer (a) Trichomonas to annual repeat if adequate history of (b) Fungal organisms consistent mor- normal Pap tests phologically with candida species 2. Organisms (c) Shift in vaginal flora suggestive of a. Trichomonas vaginalis—highly predictive bacterial vaginosis but not 100%; treat if indicated (d) Bacteria morphologically consis- b. Candida species—most are asymptomatic tent with actinomyces species colonization and require no treatment; if (e) Cellular changes consistent with symptomatic treat herpes simplex virus c. Bacterial vaginosis—correlate with clinical (3) May report other nonneoplastic findings; treat if indicated findings d. Actinomyces—evaluate for signs/ symptoms of pelvic infection if intrauterine contraceptive (IUC) present; if has 236 Chapter 7 Gynecological Disorders

pelvic infection remove IUC and treat with defer colposcopy until at least 6 weeks antibiotics, otherwise no treatment or IUC postpartum removal needed (4) Immunosuppressed; includes all in- e. Herpes simplex virus—high predictive fected with human immunodeficiency value; counsel client virus (HIV)—manage same as women 3. Reactive changes associated with who are not immunosuppressed inflammation b. ASC-H—colposcopic examination a. Examine—microscopy, STD tests as recommended indicated c. LSIL b. Treat any identified cause (1) Colposcopic examination c. It is of no value to treat empirically with (a) No CIN2/3—repeat pap test at 6 topical sulfa cream and 12 months or HPV DNA test- d. Repeat Pap test if indicated ing at 12 months; if greater than 4. Endometrial cells in premenopausal woman or equal to ASC-US or HPV +, re- with normal menstrual pattern—insignificant; peat colposcopy must be evaluated with endometrial biopsy in (b) CIN 2/3—refer to specialist postmenopausal woman or in premenopausal (2) Postmenopausal women—options woman with abnormal bleeding include repeating Pap test at 6 and 12 5. Atrophy—treat if symptomatic months, HPV-DNA testing for high- 6. Epithelial cell abnormalities risk types, immediate colposcopy a. ASC-US (3) Pregnant women—colposcopic exam- (1) Options include repeating Pap test ination by clinician familiar with cer- at specified intervals, HPV-DNA test- vical changes induced by pregnancy; ing for high-risk types, immediate endocervical curettage should not be colposcopy done; acceptable to defer colposcopy (a) Repeat Pap test at 6 months; if until at least 6 weeks postpartum negative repeat again in 6 months; (4) Immunosuppressed; includes all in- if second repeat is negative return fected with human immunodeficiency to routine screening; any further virus (HIV)—manage same as women ASC or greater do colposcopy who are not immunosuppressed (b) HPV-DNA testing for high-risk d. HSIL—colposcopic examination is recom- types; if positive refer for colpos- mended; for women in whom future fertil- copy; if negative repeat Pap test in ity is not an issue may consider immediate 12 months loop electrosurgical excision (c) Immediate colposcopy e. Squamous cell carcinoma—refer to i. No CIN/cancer and high- specialist risk HPV either negative or f. AGC—all subcategories except atypical unknown—repeat Pap test in endometrial cells 12 months (1) Colposcopic examination with endo- ii. No CIN/cancer and positive cervical sampling for high-risk HPV—repeat (2) Include endometrial sampling if 35 Pap test at 6 and 12 months years of age or older, or abnormal or repeat HPV-DNA testing in bleeding 12 months; repeat colposcopy g. AGC with atypical endometrial cells— for any abnormal findings in include endometrial sampling regardless follow-up of age iii. CIN/cancer—refer to h. Adenocarcinoma—refer to specialist specialist (2) Postmenopausal women with clinical Â Questions evidence of atrophy—treat with estrogen vaginal cream for 4–6 weeks and Select the best answer. repeat Pap test; if negative repeat in 4–6 months; if negative at 4–6 months 1. Premenstrual syndrome is suspected when a return to routine screening interval; if woman experiences symptoms only during: ASC-US or greater refer for colposcopy a. Ovulation (3) Pregnant women—manage same as b. The luteal phase nonpregnant woman; acceptable to Questions 237

c. The LH surge c. Fixed retroverted uterus d. The follicular phase d. Prolapsed uterus 2. Primary dysmenorrhea can best be treated with: 10. The most common benign neoplasm of the cervix is: a. Dopamine agonists b. GnRH agonists a. Bartholin gland cyst c. Prostaglandin inhibitors b. Squamous papilloma d. Tricyclic antidepressants c. Pedunculated myoma d. Polyp 3. The most common cause for chronic pelvic pain in reproductive age women is: 11. A 22-year-old female presents with complaint of malodorous vaginal discharge and vulvar itching. a. Adenomyosis On examination a watery, yellowish-green b. Endometriosis vaginal discharge is noted along with vulvar and c. Pelvic inflammatory infection vaginal erythema. The most likely findings on a d. Uterine fibroids wet mount examination will be: 4. Which of the following contraceptive methods a. Clue cells has also been FDA approved for treatment of b. Lactobacilli endometriosis? c. Pseudohyphae a. Combination oral contraceptive pills d. Trichomonads b. Levonorgestrel IUS 12. Characteristics of Turner’s syndrome include: c. Progestin only contraceptive pills d. Sub Q 104 DMPA a. Uterus absent, ovaries absent b. Uterus absent, ovaries present 5. A complication of pelvic inflammatory disease is: c. Uterus present, ovaries absent a. Adenomyosis d. Uterus present, ovaries present b. Endometriosis 13. A 58-year-old woman complains of severe vulvar c. Infertility pruritus. On genital examination you note thin d. Irritable bowel syndrome skin and purpura on the vulva. You suspect the 6. The most common cause of urge urinary inconti- diagnosis may be: nence is: a. Lichens sclerosus a. Detrusor irritability b. Local allergic reaction b. Neuromuscular injury c. Lichen simplex chronicus c. Pelvic organ prolapse d. Vulvodynia d. Sphincter incompetence 14. A virginal 18-year-old presents for contraception, 7. During a vaginal examination, you observe stating she plans to become sexually active. Upon bulging of the anterior wall when you ask the examination you see an ulcerative, irregular patient to bear down. This is most likely a: lesion in the vaginal fornix. The lesion has a reddish appearing granular base. The lesion is a. Congenital abnormality likely: b. Cystocele c. Rectocele a. Genital herpes d. Uterine prolapse b. Lymphogranuloma venerum c. Toxic shock syndrome 8. The definitive diagnosis of endometriosis is made d. Ulceration from tampon injury with: 15. Which of the following is true concerning dys- a. CT scan functional uterine bleeding? b. Laparoscopy c. Serum CA 125 a. Appropriate diagnosis for bleeding until d. Transvaginal ultrasound definitive diagnosis is made b. Most often occurs in women ages 20–40 9. Adenomyosis can be suspected when a woman c. Usually associated with anovulatory cycles has a/an: d. Usually associated with abnormal pelvic a. Boggy, tender uterus exam findings b. Enlarged irregularly shaped uterus 238 Chapter 7 Gynecological Disorders

16. Hirsutism is most commonly seen with: 23. A known risk factor for cancer of the cervix is: a. Androgen insensitivity syndrome a. Cigarette smoking b. Asherman’s syndrome b. Early menarche c. Polycystic ovarian syndrome c. Multiparity d. Turner’s syndrome d. Uncircumcised partner 17. A 22-year-old experiences 6 months of amen- 24. Polycystic ovarian syndrome predisposes to an orrhea. Laboratory test results include normal increased incidence of: prolactin and thyroid stimulating hormone and a. Adrenal tumors negative pregnancy test. The next action will be b. Endometriosis to: c. Endometrial cancer a. Administer progestin challenge test d. Ovarian cancer b. Measure testosterone 25. In which of the following conditions would you c. Order hysterosalpingogram expect to have a positive progestin challenge d. Order MRI or CT scan of pituitary gland test? 18. The most common cause of menstrual abnor- a. Androgen insensitivity syndrome mality in a reproductive age woman is: b. Asherman’s syndrome a. Adenomyosis c. Polycystic ovarian syndrome b. Anovulation d. Turner’s syndrome c. Coagulopathy 26. The most common presenting symptom of vulvar d. Ectopic pregnancy cancer is: 19. The pain of primary dysmenorrhea is: a. Bleeding a. Always associated with pathology such as b. Pruritus endometriosis c. Vaginal discharge b. Colicky, spasmodic, sometimes radiating up d. Vaginal odor the back to the shoulders 27. A nonpregnant patient diagnosed with chla- c. Colicky, spasmodic, sometimes radiating to mydia is allergic to azithromycin. An alternative the thighs and low back treatment is: d. Dull ache associated with underlying pathology a. Ciprofloxacin b. Doxycycline 20. A 16-year-old woman has not yet begun men- c. Penicillin struating, but does have pubic hair. She is best d. Trimethoprim described as having: 28. A 26-year-old female has a Pap test report of a. Asherman’s syndrome ASC-US. This is her first abnormal Pap test. b. Oligomenorrhea HPV-DNA testing is negative for high-risk HPV c. Primary amenorrhea types. Recommended follow-up would include: d. Secondary amenorrhea a. Colposcopy in 6 months 21. Which of the following is the most accurate b. Repeat Pap smear in 4 to 6 months method to predict the occurrence of ovulation? c. Repeat HPV-DNA testing in 1 year a. Huhner’s test d. Repeat Pap test in 1 year b. Evaluation of cervical mucus 29. A treatment for atrophic vaginitis with the goal c. LH surge test of prevention of recurrence is: d. Basal body temperature a. Antifungal cream 22. Toxic shock syndrome should be suspected in b. Low potency topical steroids a woman presenting with sudden-onset fever, c. Oral progestin therapy flulike symptoms, recent tampon use and: d. Topical estrogen cream a. Dysuria 30. A 24-year-old woman presents with complaint b. Heavy vaginal bleeding of nontender mass in her left breast that does c. Pale conjunctiva and vaginal walls not change with menstrual cycle. On examina- d. Macular rash on face and trunk tion you note a freely moveable, 0.5 cm x 1 cm, Questions 239

firm, rubbery nontender mass. The most likely firm pelvic mass anterior to the uterus. The most diagnosis is: likely diagnosis is: a. Fibroadenoma a. Benign cystic teratoma b. Fibrocystic breast changes b. Ectopic pregnancy c. Intraductal papilloma c. Endometrioma d. Cystosarcoma phyllodes d. Follicular cyst 31. The Bethesda system equivalent for moderate 38. Unopposed estrogen may predispose a 52-year- dysplasia or CIN III on a Pap test is: old woman to: a. Atypical glandular cells of undetermined sig- a. Endometrial hyperplasia nificance (AGS-US) b. Fibrocystic breast changes b. Carcinoma in situ c. Follicular cysts c. High grade squamous epithelial lesion d. Ovarian carcinoma d. Low-grade squamous intraepithelial lesion 39. A diagnosis of stress urinary incontinence is con- 32. Potential causes for galactorrhea include all of firmed on the basis of: the following except: a. Probable etiology a. Heavy tobacco use b. Pelvic muscle tone evaluation b. Hypothyroidism c. Urodynamic testing c. Opiate use d. Symptom profile d. Pituitary adenoma 40. The most common presenting symptom of cer- 33. Leiomyomata arising from tissue within the vical cancer is: uterine wall are: a. Dyspareunia a. Interstitial b. Lower abdominal pain b. Pedunculated c. Irregular bleeding c. Subserosal d. Yellow vaginal discharge d. Submucosal 41. The first step in the evaluation of HSIL Pap test 34. The most common presenting symptom of leio- result is: myomata uteri is: a. HPV DNA testing a. Infertility b. Colposcopic evaluation with endocervical b. Menorrhagia biopsy c. GI symptoms c. Endometrial biopsy d. Urinary frequency d. Repeat Pap test at 6 and 12 months 35. Another name for a dermoid cyst is: 42. Persistent vague abdominal pain or discomfort in a 65-year-old woman may be an early sign of: a. Benign cystic teratoma b. Follicular cyst a. Choriocarcinoma c. Hyperplastic endometroma b. Benign cystic teratoma d. Müllerian cyst c. Endometrial cancer d. Ovarian cancer 36. Your examination of a female patient indicates that she has external genital warts. You will want 43. A risk factor for endometrial cancer is: to explain to her that: a. DES exposure a. Her partner needs a blood test to see if he b. Early menopause has subclinical infection. c. Obesity b. She should have Pap tests every 6 months. d. Multiparity c. There is no therapy that will eliminate the 44. The most lethal gynecological malignancy is: HPV virus. d. You cannot start treatment until you have a. Cervical carcinoma her Pap test results. b. Choriocarcinoma c. Endometrial carcinoma 37. A 36-year-old is seen in your office on day 18 of d. Ovarian carcinoma her cycle for her routine annual examination. She has no complaints. Pelvic exam reveals a 9 cm 240 Chapter 7 Gynecological Disorders

45. A positive “whiff” or amine test is suggestive of: a. Ceftriaxone b. Famcyclovir a. Atrophic vaginitis c. Silver nitrate b. Bacterial vaginosis d. Tetracycline c. Chronic lichens sclerosus d. Recurrent candidiasis 53. A lesion of secondary syphilis is: 46. An indicator of loss of lactobacilli in the vagina a. Condyloma acuminata is: b. Condyloma lata c. Molluscum contagiosum a. Elevated pH d. Inguinal bubo b. Increased WBC on wet mount c. Malodorous vaginal discharge 54. Primary syphilis may be suspected when the d. Vaginal itching patient presents with: 47. Trichomoniasis is best treated with: a. A maculopapular rash b. An indurated, painless ulcer on the cervix a. Oral fluconazole c. Enlarged, tender inguinal lymph nodes b. Oral metronidazole d. Tender vesicles and papules on the vulva c. Topical clindamycin cream d. Topical metronidazole cream 55. Herniation of the bladder into the vagina is called: 48. Which of the following treatments for genital warts may be used during pregnancy? a. Cystocele b. Enterocele a. Imiquimod cream c. Urethrocele b. Podophyllin resin d. Vaginal prolapse c. Podofilox gel d. Trichloracetic acid 56. A 66-year-old woman with a history of pruritus presents with an ulceration of the vulva. The 49. A sexually active 18-year-old presents with post- most likely diagnosis is: coital spotting, dysuria, and a yellow discharge. On exam you find her cervix is erythematous and a. Chancroid bleeds with contact. The most likely diagnosis is: b. Secondary trauma c. Syphilis a. Cervical cancer d. Vulvar carcinoma b. Chlamydia c. Primary syphilis 57. A 26-year-old woman presents with multiple, d. Tampon injury painless, umbilicated papules on her mons pubis. The most likely diagnosis is: 50. Risk factors for ovarian cancer include: a. Condyloma acuminata a. Diabetes b. Condyloma lata b. Late menopause c. Lymphogranuloma venereum c. History of human papillomavirus d. Molluscum contagiosum d. Oral contraceptive pill use for more than 5 years 58. Which of the following statements concerning herpes genitalis is true? 51. Recommendations for repeat testing after treatment for chlamydia with doxycycline include: a. Suppressive therapy does not reduce viral shedding. a. Test of cure 1 to 2 weeks after treatment if b. Systemic symptoms are uncommon during suspect noncompliance recurrences. b. Test of cure 3 to 4 weeks after treatment for c. Topical acyclovir is as effective as oral acy- all patients clovir for recurrences. c. Test for possible reinfection 1 month after d. Transmission of the virus is unlikely to occur treatment during the prodromal phase. d. Test for possible reinfection 3 months after treatment 59. Disorders of pelvic support may be associated with all of the following except: 52. Effective treatment for the symptomatic relief of herpes genitalis is: a. Obesity b. Neuromuscular injury during childbirth Questions 241

c. Pelvic surgery a. Adnexal mass d. Frequent urinary tract infections b. Cervical motion tenderness c. Fever higher than 101°F (> 38.4°C) 60. A 58-year-old woman complains that she feels d. Vaginal discharge she’s “sitting on a ball.” She has significant constipation and rectal pressure. On examination 68. Androgen insensitivity syndrome was previously you will most likely find: known as: a. Cystocele a. Fragile X syndrome b. Hemorrhoid b. Marfan’s syndrome c. Rectocele c. Müllerian agenesis d. Urethrocele d. Testicular feminization 61. Vaginal cancer is most commonly found in which 69. The gonads should be removed after puberty in part of the vagina? a person with androgen insensitivity syndrome to prevent: a. The hymenal ring b. Midway of the vagina a. Endometrial hyperplasia c. The posterior fourchette b. Gonadal malignancies d. The upper one-third of the vagina c. Increased risk for breast cancer d. Psychological trauma 62. Females exposed to DES in utero are at increased risk for: 70. The most common method of assisted reproductive technology is: a. Breast cancer b. Ovarian cancer a. Gamete intrafallopian transfer (GIFT) c. Vaginal cancer b. Intracytoplasmic sperm injection (ICZI) d. Vulvar cancer c. In vitro fertilization (IVF) d. Zygote intrafallopian transfer (ZIFT) 63. Anticholinergic agents may be used in the treatment of: 71. Turner’s syndrome can be suspected when the patient has primary amenorrhea and: a. Stress incontinence b. Urge incontinence a. Blind vaginal pouch with imperforate hymen c. Vestibulitis b. Low IQ and visual disturbances d. Vulvodynia c. Normal breast development but lack of pubic and axillary hair growth 64. The most common gynecological neoplasm is: d. Short stature and webbed neck a. Adenocarcinoma 72. The most common chromosomal abnormality in b. Adenosarcoma spontaneous aborted fetuses is: c. Choriocarcinoma d. Leiomyoma a. Fitz-Hugh-Curtis syndrome b. Fragile X syndrome 65. The most common cause of pathologic nipple c. Müllerian duct abnormalities discharge in perimenopausal women is: d. Turner’s syndrome a. Breast cancer 73. Reactive cellular changes on a Pap test report are b. Fibroadenoma most likely the result of: c. Intraductal papilloma d. Prolactin secreting pituitary adenoma a. Inflammation b. Low-grade epithelial lesion 66. The most common germ-cell tumor is: c. Glandular cell abnormalities a. Benign cystic teratoma d. Oral contraceptive use b. Choriocarcinoma 74. A patient with latent syphilis may present with: c. Embryonal carcinoma d. Vaginal agenesis a. A maculopapular rash b. An indurated painless ulcer 67. An examination finding that is considered c. Condyloma lata minimum criteria for empirical treatment of PID d. No signs of infection in a sexually active young woman presenting with lower abdominal or pelvic pain is: 242 Chapter 7 Gynecological Disorders

75. CDC recommendations for follow up of female Â Answers treated for PID with a recommended outpatient regimen is: â 1. b 41. b a. Advise patient to return if pain and/or fever â 2. c 42. d persists more than 5 days â 3. b 43. c b. Reexamine patient within 72 hours after ini- â 4. d 44. d tiation of treatment â 5. c 45. b c. Retest for chlamydia and gonorrhea in 2 â 6. a 46. a weeks â 7. b 47. b d. See patient in 1 week for second dose of cef- â 8. b 48. d triaxone IM â 9. a 49. b 76. Which of the following medications is most likely 10. d 50. b to cause a metallic taste? 11. d 51. d a. Acyclovir 12. c 52. b b. Azithromycin 13. a 53. b c. Fluconazole 14. d 54. b d. Metronidazole 15. c 55. a 77. A patient-applied treatment for human papillo- 16. c 56. d mavirus (HPV) is: 17. a 57. d 18. b 58. b a. Bichloracetic acid b. Clindamycin cream 19. c 59. d c. Imiquimod 20. c 60. c d. Podophyllin resin 21. c 61. d 22. d 62. c 78. Risk factors for breast carcinoma include: 23. a 63. b a. Early menopause 24. c 64. d b. History of endometrial cancer 25. c 65. c c. Multiparity 26. b 66. a d. History of intraductal papilloma 27. b 67. b 79. Characteristic “strawberry spots” on the cervix 28. d 68. d may be seen with: 29. d 69. b a. Bacterial vaginosis 30. a 70. c b. Chlamydia 31. c 71. d c. Herpes genitalis 32. a 72. d d. Trichamoniasis 33. a 73. a 80. Typical characteristics of vulvodynia include: 34. b 74. d 35. a 75. b a. Constant vulvar burning and discomfort b. Inflammation of the vestibular glands 36. c 76. d c. Thickened plaques on vulva 37. a 77. c d. Vulvovaginal edema and erythema 38. a 78. b 39. c 79. d 40. c 80. a Bibliography 243

Â Bibliography Ferri, F. F. (Ed.). (2008). Ferri’s clinical advisor: Instant diagnosis and treatment. St. Louis: Mosby, Inc. American College of Obstetricians and Gynecologists Katz, V., Lentz, G., Lobo, R., & Gershenson, D. (2007). (ACOG). (2009). Cervical cytology screening. Practice Comprehensive gynecology (5th ed.). Philadelphia, Bulletin, 109. Washington, DC: Author. PA: Mosby, Inc. American College of Obstetricians and Gynecologists North American Menopause Society. (2007). Menopause (ACOG). (2008). Management of abnormal cervical practice: A clinician’s guide (3rd ed.). Cleveland, OH: cytology and histology. Practice Bulletin, 99. Wash- NAMS. ington, DC: Author. Schuiling, K., and Likis, F. (2006). Women’s gynecologic American College of Obstetricians and Gynecologists health. Sudbury, MA: Jones and Bartlett. (ACOG). (2008). Treatment of urinary tract infections Solomon, D., Davey, D., Kurman, R., Moriarty, A. et al. in nonpregnant women. Practice Bulletin, 91. Wash- (2002). Consensus statement: The 2001 Bethesda ington, DC: Author. system—terminology for reporting results of cervical American College of Obstetricians and Gynecologists cytology. JAMA, 287(16), 2114–2119. (ACOG). (2005). Urinary incontinence in women. Speroff, L., Glass, R. H., & Kase, N. G. (2005). Clinical Practice Bulletin, 63. Washington, DC: Author. gynecologic endocrinology and infertility (7th ed.). American College of Obstetricians and Gynecologists Baltimore, MD: Williams and Wilkins. (ACOG). (2004). Chronic pelvic pain. Practice Bulle- Tharpe, N., & Farley, C. (2009). Clinical practice guide- tin, 51. Washington, DC: Author. lines for midwifery and women’s health (3rd ed.). Sud- Centers for Disease Control and Prevention (CDC). bury, MA: Jones and Bartlett. (2006). Guidelines for treatment of sexually transmit- Wright, T., Massad, S., Dunton, J., Spitzer, M., Wilkin- ted diseases. MMWR 2006, 55(No. RR-11). Atlanta, son, E., & Solomon, D. (2007). 2006 consensus guide- GA: Author. lines for the management of women with abnormal Chernecky, C., & Berger, B. (2008) Laboratory tests and cervical cancer screening tests. American Journal of diagnostic procedures (5th ed.). St. Louis: Saunders Obstetrics and Gynecology, 197(4), 346–355. Elsevier. Wynne, A., Woo, T., & Olyaei, A. (2007). Pharmacothera- Gibbs, R., Karlan, B., Haney, A., & Nygaard, I. (2008). peutics for nurse practitioner prescribers (2nd ed.). Danforth’s obstetrics and gynecology (10th ed.). Phila- Philadelphia, PA: F. A. Davis. delphia, PA: Williams, Wilkins, and Wolters.

8 Nongynecological Disorders/Problems

Sandra K. Pfantz Beth M. Kelsey Mary C. Knutson

¶ CARDIOVASCULARDISORDERS (6) Microalbuminuria or estimated glomerular filtration rate (GFR) of less Hypertension than 60 mL/min (7) Age older than 55 in men and older UÊ ivÌ than 65 in women 1. Systolic blood pressure (SBP) of 140 mm Hg (8) Family history of premature car- ÀÊ}Ài>ÌiÀ]ÊÀÊ`>ÃÌVÊL`Ê«ÀiÃÃÕÀiÊ *®ÊvÊ diovascular disease (men < 55 and äÊÊ}ÊÀÊ}Ài>ÌiÀ]Ê>ÃÊi>ÃÕÀi`ÊLÞÊ>ÌÊi>ÃÌÊ women < 65) two readings on two or more separate visits; or Ì>}Ê>Ì Þ«iÀÌiÃÛiÊi`V>ÌÊ * *]Ê UÊ Ì}ÞÉVìVi 1997) £°Ê Ì}Þ Ó°Ê >ÃÃvV>ÌÊvÊL`Ê«ÀiÃÃÕÀiÊ * *]Ê a. Primary or essential 2003) (1) No discernible cause; a complex poly- Classification SBP DBP genic and multifactorial disorder Normal < 120 and < 80 (2) Comprises 90–95% of diagnosed cases Prehypertension 120–139 or 80–90 b. Secondary Stage 1 hypertension 140–159 or 90–99 (1) Underlying disease or condition iden- Stage 2 hypertension ≥ 160 or ≥ 100 tified; requires separate treatment Î°Ê Û>Õ>ÌÊvÊ«>ÌiÌÃÊÜÌ Ê`VÕiÌi`Ê Þ- (2) Comprises 5–10% of adult cases pertension has three objectives: Ó°Ê VìVi a. To identify secondary causes a. 10–15% of Caucasian adults L°Ê /Ê>ÃÃiÃÃÊvÀÊÌ>À}iÌÊÀ}>Ê`>>}iÊ/" ®p b. 20–30% of African-American adults iÞi]ÊLÀ>]ÊL`ÊÛiÃÃiÃ]Ê i>ÀÌ]Ê>`ÊìÞ V°Ê `Û`Õ>ÃÊÀÌiÃÛiÊ>ÌÊ>}iÊxxÊ >ÛiÊ>Ê c. To identify other cardiovascular risk fac- ä¯ÊviÌiÊÀÃÊ * *]ÊÓääÎ® tors or concomitant disorders that may define prognosis and guide therapy. Major UÊ -}ÃÊ>`ÊÃÞ«ÌÃ cardiovascular risk factors include: 1. Symptoms usually not present (1) Smoking Ó°Ê ÊV>ÃiÃÊvÊÃiV`>ÀÞÊ Þ«iÀÌiÃ]Ê>ÞÊ Ó®Ê "LiÃÌÞÊ Ê≥ 30) be symptoms associated with secondary (3) Physical inactivity condition {®Ê ÞÃ«ì> a. Weakness in primary aldosteronism x®Ê >LiÌiÃÊiÌÕÃ b. Truncal obesity and purple striae in Cush- ing’s syndrome

245 246 Chapter 8 Nongynecological Disorders/Problems

c. Palpitations, tremor and sweating in 3. Optional studies pheochromocytoma a. Measurement of urinary albumin excre- 3. In chronic hypertension, may be symptoms tion or albumin/creatinine ratio associated with TOD b. TSH a. Symptoms associated with peripheral vas- c. Intravenous Pyelogram (IVP) to rule out cular disease, coronary artery disease and renovascular disease heart failure d. 24-hour urine for metanephrines b. Symptoms associated with stroke or tran- and catecholamines to rule out sient ischemic attack pheochromocytoma e. Chest radiograph to rule out cardiomegaly • Physical findings and coarctation of the aorta 1. Elevated blood pressure as noted in definition f. Echocardiogram is more sensitive study to 2. Findings associated with secondary causes or detect LVH TOD a. Retinopathy • Management/Treatment (NHBPEP, 2003/JNC 7)

b. S4 gallop, S3 gallop, precordial heave, and 1. Goals of therapy displaced point of maximal impulse a. Prevent/minimize TOD c. Renal artery bruit in renal artery stenosis b. Focus on achievement of systolic BP goal; d. Delayed or absent femoral pulses and de- most patients will achieve diastolic goal creased blood pressure in lower extremi- once systolic BP is at goal (< 140/90) ties in coarctation of the aorta c. BP goal in patients with coronary heart e. Diminished or absent peripheral pulses, disease (CHD), diabetes, abdominal aortic edema aneurysm, peripheral arterial disease, ca- f. Neurologic findings rotid artery disease, 10-year Framingham risk score of 10% or greater, or renal dis- • Differential diagnosis/Secondary causes ease is less than 130/80 1. Sleep apnea 2. Nonpharmacologic—life style modifications 2. Chronic kidney disease recommended for all patients 3. Primary aldosteronism a. Weight reduction—maintain ideal body 4. Renovascular disease weight 5. Chronic steroid therapy and Cushing’s b. Adopt DASH eating plan—diet rich in syndrome fruits, vegetables, and low-fat dairy prod- 6. Pheochromocytoma ucts with a reduced content of saturated 7. Coarctation of the aorta and total fat 8. Thyroid or parathyroid disease c. Dietary sodium reduction—6 g NaCl 9. Drug-induced or drug-related d. Physical activity—engage in aerobic physi- a. Drug abuse—cocaine, amphetamines, cal activity at least 30 minutes per day alcohol most days of the week b. Combination hormonal contraception e. Moderation of alcohol consumption c. Sympathomimetics—OTC cold remedies f. Stop smoking 3. Pharmacologic • Diagnostic tests/findings a. General principles of therapy 1. Recommended before initiating therapy to (1) For most patients, thiazide-type rule out secondary causes, determine the pres- diuretics should be used as initial ence of risk factors, and assess for TOD therapy either alone or in combina- 2. Recommended initial laboratory tests tion with an agent from one of the a. Urinalysis following classes: ACE inhibitors, b. CBC angiotensin-receptor blockers (ARBs), c. Blood glucose, serum potassium, creat- beta-blockers, or calcium channel inine or estimated GFR, calcium, lipid blockers (CCBs) profile (a) Prehypertension—no drug ther- (1) Hypokalemia in primary apy indicated aldosteronism (b) Stage 1 HTN—thiazide-type (2) Elevated creatinine in renal disease diuretic d. Electrocardiogram (ECG) to assess evi- (c) Stage 2 HTN—two drug regimen dence of ischemic heart disease or left for most; usually thiazide diuretic ventricular hypertrophy (LVH) plus ACE inhibitor, ARB, beta- blocker, or CCB Cardiovascular Disorders 247

(2) Compelling indications requiring the 2. Classification use of other agents as initial therapy a. Innocent or functional murmurs (a) Ischemic heart disease (1) Transient; pose no direct threat to i. Stable angina—beta-blocker; health long-acting CCB as an (2) Most frequently heard during systole alternative (3) No structural or functional cardiac ii. Post-MI—ACE inhibitors, abnormality beta-blockers, aldosterone (4) Often noted in pregnancy due to in- antagonist creased cardiac output (b) Diabetes—ACE inhibitors or ARBs b. Pathologic murmurs are indicative of favorably affect progression of heart or valvular disease, e.g., aortic or nephropathy pulmonary stenosis, atrial septal defect, (3) Most patients will require two or more rheumatic heart disease antihypertensive agents to reach their BP goal • Etiology/Incidence b. Classification of drugs for hypertension by 1. Etiology drug action (see Table 8-1) a. Turbulent blood flow into, through, or out (1) Diuretics of the heart can result in audible murmur (a) Commonly employed as initial b. Characteristics of sound depend upon the therapy following factors: (b) Blacks and elderly respond well; (1) Size of valve opening drug of choice isolated systolic (2) Integrity of valve hypertension (3) Vigor of contraction (2) Sympatholytic agents (4) Rate of flow (a) Beta adrenergic blockers (5) Thickness of chest wall (b) Peripheral alpha 1 blockers 2. Incidence (c) Central alpha 2 receptor agonists a. Innocent systolic murmurs occur in 50– (3) Calcium channel blockers 70% of children and up to 50% of adults at (a) Dihydropyridines some time (b) Diltiazem, Verapamil b. Pathologic murmurs are less common but (4) ACE inhibitors incidence increases with age (a) Indicated in diabetics with (1) Congenital—Marfan’s syndrome, valve proteinurea malformation (b) Blacks and elderly respond less (2) Acquired—Rheumatic heart disease, well; use with diuretic mitral valve prolapse (MVP) (5) Angiotensin-receptor blockers (6) Direct vasodilators • Signs and symptoms 4. Patient education 1. Innocent murmurs—not symptomatic a. Lifelong nature of hypertensive condition 2. Pathologic b. Asymptomatic nature of hypertension a. Possible chest pain c. Adherence to treatment regimens reduces b. Shortness of breath on exertion complications and deaths c. Orthopnea d. Critical to comply with recommended d. Cough or wheeze follow-up and monitoring schedule e. Paroxysmal nocturnal dyspnea f. Growth failure • Referral 1. Evaluation and management of secondary • Physical findings causes 1. Innocent 2. Resistance to drug therapy; failure to respond a. Usually none except audible murmur to three-drug regimen that includes a diuretic b. Soft (grade 1 or 2 intensity), medium pitch, systolic murmur Heart Murmurs c. Heard best when patient is supine d. Disappears with standing or straining • Definition e. Increases with increased cardiac output, 1. Prolonged extra heart sounds heard during ei- e.g., fever, exercise ther systole or diastole; commonly associated with dynamics of regurgitation or stenosis 248 Chapter 8 Nongynecological Disorders/Problems Contraindications Precaution in pregnancy and nursing mothers Anuria; sulfonamide allergy; pregnancy category B/C; not recommended for nursing mothers Anuria, hepatic coma, lactation; pregnancy category C; caution in nursing mothers Renal impairment, anuria, hyperkalemia; caution in pregnancy; not recommended for nursing mothers Asthma, congestive heart failure, type 1 diabetes, disease; pregnancy Raynaud’s category C; not recommended while nursing Interactions Hypotension with other antihypertensives Enhances other classes of antihypertensives; may decrease oral sulfonylurea drug efficacy; raises serum lithium levels Ototoxicity with aminogylcosides May exacerbate hyperkalemia with ACE inhibitors blunted by NSAIDs; Effects masks/prolongs insulin- induced hypoglycemia Side-effects Orthostatic hypotension, syncope with first dose Increases cholesterol and glucose levels; decreases potassium, sodium, magnesium levels; increases uric acid, calcium levels; blood dyscrasias rarely, Dehydration, electrolyte imbalance Hyperkalemia, hyponatremia GI disturbances, rash, gynecomastia Bronchospasm, bradycardia, heart failure, may mask insulin-induced hypoglycemia, insomnia, fatigue, decreased exercise tolerance

1 Action receptors on arterioles and veins Inhibits sodium reabsorption from distal renal tubules; reduced sodium results in decreased vascular tone Inhibits sodium reabsorption from ascending Loop of Henle Inhibits sodium exchange for potassium in distal tubule Inhibits sympathetic stimulation of the heart; blocks renin release from kidney Inhibits stimulation of alpha Hypertension Pharmacology (representative list) Drug Name Hydrochlorothiazide Indapamide Ethacrynic acid Furosemide Spironolactone Triamterene Propranolol Atenolol Prazosin Terazosin Table 8-1 â Table Â Diuretics Thiazides â â Loop diuretics â â Potassium-sparing agents â â Sympatholytic agents Beta-adrenergic blockers â â Alpha-adrenergic blockers â â Cardiovascular Disorders 249 Pregnancy category B; not recommended nursing mothers Congestive heart failure, A-V block, pregnancy category C; do not use while nursing Bilateral renal artery stenosis, pregnancy category C (1st trimester), D (2nd & 3rd trimester); use with caution while nursing Pregnancy category C (1st trimester), D (2nd & 3rd trimester); not recommended while nursing Pheochromocytoma; pregnancy Category C; not recommended while nursing antidepressants & beta-adrenergic Verapamil blockers have additive cardiodepressive effects Antacids reduce bioavailability; effects blunted by NSAIDs Hyperkalemia with potassium sparing diuretics, potassium supplements Guanethidine Dry mouth, sedation Antagonized by tricyclic dizziness, Tachycardia, headache, edema, conduction defects, heart failure Common: cough; rare: angioedema, hyperkalemia, rash, loss of taste Similar to ACE inhibitors, but do not cause cough; rare: angioedema. headache Tachycardia, aggravation of angina, fluid retention Decreases sympathetic outflow; results in decreased cardiac output and PVR Decreases myocardial contractility and peripheral resistance Inhibits angiotensin- converting enzyme; prevents conversion of angiotensin I to angiotensin II; a potent vasoconstrictor to receptor Act on vascular smooth muscle to cause dilation of arterioles Clonidine Methyldopa Diltiazem Verapamil Central alpha adrenergic agonists â â Calcium antagonists Nifedipine â â ACE inhibitors Captopril Enalapril blockers Angiotensin II receptor Losartin, Valsartan Block binding of angiotensin II Minoxidil Hydralazine 250 Chapter 8 Nongynecological Disorders/Problems

2. Pathologic a. Deep vein thrombosis (DVT), acute or a. Diastolic murmur or any murmur above recurrent grade 3 b. Superficial thrombophlebitis b. Intensifies with exercise or Valsalva maneuver • Etiology/Incidence/Risk factors c. Click, associated with MVP, pulmonic 1. Etiology stenosis, aortic stenosis a. Origin of most venous thrombi lie in Vir- d. Cyanosis chow’s triad—endothelial damage, stasis, e. Jugular vein distension hypercoagulability f. Hepatomegaly (1) Endothelial damage secondary to g. Pedal edema trauma h. Diminished femoral pulses or unequal (2) Stasis secondary to immobility blood pressure in left and right arms (3) Hypercoagulability secondary to protein deficiency states such as protein • Differential diagnosis—focused on differentiating C or S, antithrombin III; nephrotic innocent versus pathologic murmur syndrome, chronic liver disease, and certain malignancies • Diagnostic tests/findings—indicated only if patho- b. DVT occurs as blood clots form within the logic murmur suspected deep venous plexus of the calf or within 1. Echocardiography—confirms severity, location the popliteal, femoral, iliac veins of clinically detected lesions c. Approximately 40% of DVTs embolize to 2. Chest radiograph—suspected cardiac pulmonary circulation when thigh veins enlargement involved; risk minimal when only calf 3. CBC—rule out anemia veins involved 4. Thyroid function tests—rule out hyper- or d. Prevention of pulmonary embolus (PE) hypothyroidism necessitates prompt diagnosis and treatment of DVT • Management/Treatment e. Superficial thromboses usually occur in 1. Low-grade, asymptomatic systolic murmur varicose veins with low-risk history can be assumed innocent 2. Incidence and followed up at next visit a. DVT/pulmonary emboli—500,000 cases 2. Pharmacologic—bacterial endocarditis pro- annually phylaxis for susceptible patients b. Superficial thrombophlebitis—125,000 a. Patients with valvular heart disease, pros- cases annually thetic heart valves, or other structural car- 3. Risk factors diac abnormalities a. Recent surgery—gynecological or ortho- b. Indicated dental, upper respiratory, pedic procedures of the hip, knee gastrointestinal, and genitourinary b. Immobility procedures c. Advancing age—mean age for DVT is age c. Give oral amoxicillin 2 g 1 hour before 60 procedure d. Cancer—especially adenocarcinomas 3. Patient education e. Pregnancy and early postpartum a. Self-knowledge and self-disclosure in fu- f. Oral estrogen use—contraceptives and ture encounters hormone therapy b. Follow-up schedule if indicated g. Congestive heart failure or recent MI h. Prior history of thromboembolic disease • Referral i. Obesity 1. Diastolic murmurs 2. Suspected pathologic systolic murmurs • Signs and symptoms 1. DVT/superficial thrombophlebitis Thromboembolic Disease a. Acute onset of unilateral leg pain b. Local swelling, erythema, warmth • Definition 2. PE 1. Occlusion or obstruction of venous flow by a. Unilateral chest pain concomitant inflammation and clotting b. Anxiety, restlessness 2. Classifications c. Dyspnea Cardiovascular Disorders 251

• Physical findings • Management/Treatment 1. DVT—often no findings 1. Refer suspected DVT or PE for immediate a. Calf tenderness to compression; pain medical management elicited with dorsiflexion of foot (Homan’s 2. Superficial thrombophlebitis sign) a. Nonpharmacologic—elevation of leg and b. Palpable venous cord compression with an ace wrap c. Unilateral leg edema; skin may be warm b. Pharmacologic—nonsteroidal anti- and erythematous inflammatory drugs (see Acute Otitis 2. PE Media this chapter) a. Cyanosis 3. Patient education b. Diminished breath sounds over involved a. Avoid prolonged standing area b. Use of support hose c. Tachypnea d. Cough with hemoptysis Dyslipidemia e. Tachycardia f. Fever • Definition 3. Superficial thrombophlebitis 1. Increased levels of total blood cholesterol, and a. Localized area of edema, erythema and low-density lipoproteins (LDL) or triglycerides; tenderness over a superficial vein suppressed high-density lipoproteins (HDL), b. Increased temperature in surrounding or any combination; risk factor for the devel- skin opment of coronary heart disease in adults 2. Classifications using National Cholesterol • Differential diagnosis Education Program (NCEP) Adult Treatment 1. DVT Panel III (ATP III) Guidelines (NHLBI, 2001) a. Muscle strain or contusion a. Elevated LDL-C greater than 130 mg/dL b. Cellulitis—more diffuse redness b. Hypertriglyceridemia greater than 200 c. Popliteal (Baker’s) cyst mg/dL 2. PE c. Low HDL-C less than 40 mg/dL a. Myocardial infarction d. Combined dyslipidemia b. Pneumothorax e. Metabolic syndrome—any three risk c. Pneumonia factors (1) Abdominal obesity/waist • Diagnostic tests/findings circumference 1. Superficial thrombophlebitis—usually none (a) Men, greater than 40 inches indicated (b) Women, greater than 35 inches 2. DVT (2) Triglycerides greater than 150 mg/dL a. Duplex ultrasound (3) HDL-C b. Plasma D-dimer ELISA (a) Men, less than 40 mg/dL (1) Measures active breakdown of (b) Women, less than 50 mg/dL thrombi (4) Blood pressure 130/85 or greater (2) Elevated in 95–98% of DVT (5) Fasting glucose 110 or greater (3) Best used for confusing diagnoses, recurrent diagnoses • Etiology/Incidence c. Contrast venography—best used for sus- 1. Etiology pected calf vein thrombus or when clinical a. Genetic predisposition findings conflict with ultrasound b. Secondary causes 3. PE (1) Obesity a. Ventilation-perfusion (V/Q) lung scan (2) Disease processes, e.g., endocrine and b. Arterial blood gases metabolic disorders, obstructive liver c. ECG and chest radiograph disease, renal disorders d. Plasma D-dimer ELISA (3) Drugs, e.g., corticosteroids, thiazide e. Pulmonary angiogram diuretics, beta-blockers 4. Hypercoagulation states 2. Incidence—estimated 65 million Americans a. Test for protein C or S deficiency have high cholesterol b. Antithrombin III deficiency 3. Risk factors that modify LDL goals a. Cigarette smoking 252 Chapter 8 Nongynecological Disorders/Problems

b. Hypertension (BP > 140/90 or on antihy- tery disease, diabetes, or Framingham risk pertensive medication) of greater than 20% c. Low HDL cholesterol (< 40 mg/dL; > 60 b. If not, count number of CHD major risk mg/dL counts as a negative risk factor) factors d. Family history of premature coronary c. If patient has two or more risk factors, heart disease (CHD) determine the 10-year risk of a CHD event (1) CHD in male first-degree relative at with the Framingham risk tool younger than 55 years (1) Framingham risk tool calculates 10- (2) CHD in female first-degree relative at year risk of CHD event younger than 65 years (2) Website for CHD risk assessment e. Age (men ≥ 45 years; women ≥ 55 years) tool—http://www.nhlbi.nih.gov/ guidelines/cholesterol • Signs and symptoms—None except those associ- d. Assign a treatment goal for LDL-C based ated with CHD on number of risk factors or risk equivalents for CAD • Physical findings (1) LDL-C goal of less than 100—CHD or 1. Xanthomas CHD risk equivalents 2. Arcus senilis (2) LDL-C goal of less than 130—No CHD 3. Central obesity with 2 or more risk factors (10-year risk of CHD ≤ 20%) • Differential diagnosis—focused on ruling out sec- (3) LDL-C goal of less than 160—No CHD ondary causes and 0–1 risk factors 2. Nonpharmacologic/Therapeutic life style • Diagnostic tests/findings changes 1. Screening schedule a. Dietary modification a. A fasting lipoprotein profile (total choles- (1) Cholesterol reduction from diet modi- terol, LDL-C, HDL-C, TG) should be ob- fication and dietary supplements can tained every 5 years in patients 20 years or average 10–15% older (NHLBI, 2001) (2) Nutrition recommendations from b. If fasting opportunity not available at ini- NCEP tial screen, obtain total cholesterol and (a) Total fat 25–35% of total calories/ HDL-C; if total cholesterol is greater than day; less than 7% from saturated 200 or HDL-C is less than 40, have patient fat, 20% or less from monoun- return for fasting profile saturated fat, 10% or less from 2. Cholesterol classification mg/dL-ATP III polyunsaturated fat a. Total cholesterol (b) Carbohydrate 50–60% of total (1) Less than 200—desirable calories/day (2) 200–239—borderline high (c) Protein 15 g/day (3) Greater than 240—high (d) Cholesterol less than 200 mg/day b. LDL cholesterol (3) Foods/supplements (1) Less than 100 optimal (a) Fiber 20–30 g/day; 10–25 g/d (2) 100–129—near or above optimal soluble fiber (3) 130–159—borderline high (b) Plant stanols/sterols 2–3 g/d (4) 160–189—high available in margarines and salad (5) 190 or greater—very high dressings c. HDL cholesterol (c) Nuts as a snack—walnuts, (1) Less than 40—low almonds (2) 60 or greater—high (d) Substitute soy protein (e) Omega-3 fish oil capsules • Management/Treatment b. Encourage exercise for 30 min/day—this 1. Treatment of dyslipidemia is based on risk of can be walking CHD events c. Aggressive smoking cessation program a. Determine if patient has clinically mani- d. Weight loss for overweight and obese pa- fested CHD or CHD risk equivalents— tients (goal BMI < 25); initial weight loss peripheral vascular disease, abdominal goal of 5–10% of current weight aortic aneurysm, symptomatic carotid ar- Cardiovascular Disorders 253

3. Pharmacologic (3) Bile acid sequestrants a. For most patients at moderate risk, life (a) Cholestyramine (Questran), style changes should be prescribed and colestipol (Colestid), colesevelam followed for 3 months before initiating (Welchol) drug therapy; early drug therapy indicated (b) Drug action—binds cholesterol- for high-risk patients containing bile acids in intestines b. Pattern of dyslipidemia directs drug forming insoluble complex that is choice excreted (1) Elevated LDL-C—statins with niacin (c) Side-effects—gastrointestinal ef- and bile acid resins as alternatives fects, e.g., constipation, bloating, (2) Hypertriglyceridemia—niacin and nausea, cramping; no systemic fibrates toxicity (3) Low HDL-C—niacin (d) Drug interactions—may interfere (4) Combined dyslipidemia—statins, nia- with absorption of other medica- cin, fibrates tions; administer other drugs 1 c. Pharmacologic agents hour before or 3 hours after resin (1) Statins/HMG-CoA reductase (e) Contraindications/precautions— inhibitors patients with triglycerides greater (a) Atorvastatin (Lipitor), fluvastatin than 500 mg/dL and patients with (Lescol), lovastatin (Mevacor), low HDL-C; pregnancy category pravastatin (Pravachol), rosu- C; caution while nursing vastatin (Crestor), simvastatin (4) Fibric acid derivatives (Zocor) (a) Gemfibrizil (Lopid), fenofibrate (b) Drug action—inhibits HMG-CoA (Tricor) reductase, the enzyme that con- (b) Drug actions—acts primarily on trols cholesterol biosynthesis in triglyceride-rich lipoproteins, cells resulting decrease in plasma tri- (c) Side-effects—elevated liver en- glycerides, a moderate decrease in zymes and myopathy; monitor LDL-C, and an increase in HDL-C liver function (c) Side-effects—dyspepsia, gall- (d) Drug interactions—combined stones, myopathy with fibrates or niacin may in- (d) Drug interactions—may increase crease risk of myopathy risk of myopathy when combined (e) Contraindications/precautions— with statins; may potentiate effect severe liver disease; pregnancy of warfarin category X; not recommended (e) Contraindications/precautions— while nursing severe renal or hepatic disease; (2) Nicotinic acid pregnancy category C; not recom- (a) Niacin/immediate release; mended while nursing Niaspan/extended release (5) Ezetimibe (Zetia) (b) Drug action—decreases synthe- (a) Drug action—cholesterol absorp- sis of LDL-C by reducing hepatic tion inhibiter, use alone or in synthesis of VLDL cholesterol; combination with a statin increases HDL by decreasing its (b) Side-effects—back pain, arthral- catabolism gia, diarrhea, abdominal pain; (c) Side-effects—flushing, pruritus/ with statin, increase in serum decreased when premedicated transaminases with ASA; dyspepsia, hyper- (c) Drug interactions—not recom- glycemia, hyperuricemia, mended for use with fibrates; hepatotoxicity separate dosing bile acid (d) Drug interactions—additive hy- sequestrants potensive effect with antihyper- (d) Contraindications/precautions— tensives; monitor for myopathy if liver disease; pregnancy category used with statins C; not recommended in nursing (e) Contraindications/precautions— mothers liver disease, severe gout, peptic- ulcer; pregnancy category C; not recommended in nursing mothers 254 Chapter 8 Nongynecological Disorders/Problems

(6) Combination medications b. Precipitated by exertion or emotional (a) Statin plus aspirin stress and relieved by nitroglycerin (b) Statin plus calcium channel c. Chronic stable angina is predictable; no blocker change in pattern or frequency of episodes (c) Statin plus cholesterol absorption 3. Palpitations inhibitor (d) Statin plus niacin • Physical findings 4. Patient education 1. May be no specific findings a. Therapeutic life style changes 2. Elevated blood pressure b. Monitoring schedule 3. Dyspnea, tachycardia, pallor, diaphoresis during acute angina episode • Referral 1. Nutritional consultation • Differential diagnosis 2. Lipid specialist with unusually severe, refrac- 1. Unstable angina tory, or complex disorders 2. Myocardial infarction 3. Pulmonary disease—pulmonary embolism, Coronary Artery Disease pneumothorax, pneumonia 4. GI disorders—gastroesophageal reflux, chole- • Definition—atherosclerotic changes to coro- cystitis, peptic ulcer nary vasculature; decreased blood flow through 5. Musculoskeletal conditions—costochondritis, coronary arteries due to partial obstruction or muscle strain vasospasm 6. Anxiety disorders 7. Acute aortic dissection • Etiology/Incidence/Risk factors 8. Herpes zoster 1. Etiology a. Atherosclerosis develops with the forma- • Diagnostic tests/findings tion of fatty streaks, fibrous plaques, and 1. Electrocardiogram—may show transient complicated lesions that narrow the lu- T-wave inversion or ST segment depression or men of the coronary arteries elevation during acute angina episode b. Angina pectoris—myocardial ischemia 2. Exercise or pharmacologic stress testing— secondary to inability of the coronary ar- ischemic changes or angina during test is clini- teries to supply oxygenated blood to meet cally diagnostic myocardial oxygen demands 3. Myocardial perfusion imaging—used to con- c. Acute coronary syndromes—a plaque may firm and assess extent and location of coro- rupture with thrombus formation that nary artery disease impedes/completely occludes the coro- 4. Coronary angiography—definitive test for nary lumen coronary artery disease (1) Unstable angina (2) Acute myocardial infarction • Management/Treatment 2. Cardiovascular disease is the leading killer of 1. Nonpharmacologic women; one of every two women will die from a. Primary prevention—smoking cessation; coronary artery disease or stroke dietary management of hypertension, 3. Risk factors include dyslipidemia, diabetes, obesity; regular a. Cigarette smoking aerobic exercise b. Hypertension b. Secondary prevention—surgical c. Dyslipidemia revascularization d. Diabetes mellitus (1) PCTA/percutaneous transluminal e. Genetic predisposition angioplasty f. Obesity (2) CABG/coronary artery bypass graft g. Sedentary lifestyle 2. Pharmacologic—the treatment of stable angina has two major purposes: to prevent myo- • Signs and symptoms cardial infarction and to reduce the symptoms 1. May be asymptomatic of angina 2. Angina pectoris a. Primary prevention a. Clinical syndrome characterized by dis- (1) Medications for treatment of hyper- comfort in the chest, jaw, shoulder, back, tension, diabetes, hyperlipidemia, and or arm smoking cessation Eye, Ear, Nose, and Throat Disorders 255

(2) Aspirin 81–325 mg decreased myocardial oxygen b. Secondary management of angina—may demand use a combination of medications for in- (b) Side-effects—headache, dizziness, creased effectiveness flushing, orthostatic hypotension, (1) Sublingual nitroglycerine 0.4 mg as tachycardia, nausea, rash needed for symptomatic relief of angi- (c) Drug interactions—hypotension nal episodes (see Long acting nitrates potentiated with alcohol, other section) vasodilators, calcium channel (2) Beta adrenergic blockers—meto- blockers prolol, propranolol, atenolol; pre- (d) Contraindications—acute myo- ferred initial therapy in absence of cardial infarction; pregnancy cat- contraindications egory C (a) Drug action—decrease myocar- 3. Patient education dial demand by decreasing heart a. Instructions on use and side-effects of rate, systolic blood pressure, and medications contractility b. Education and support for life style (b) Side-effects—fatigue, dizziness, changes depression, bradycardia, hypotension, nausea, diarrhea, dyspnea, • Referral bronchospasm, rash 1. Patients with unstable angina (c) Drug interactions—may potenti- 2. Patients with stable angina who cannot be ate other antihypertensives, may controlled with medication antagonize effects of sympathomimetic drugs Â Eye, Ear, Nose, and Throat (d) Contraindications—sinus brady- Disorders cardia, heart block greater than one degree, heart failure, cardio- Allergic Rhinitis genic shock; pregnancy category C • Definition—inflammation of mucous membranes (3) Calcium channel blockers—verapa- of nose in response to contact with specific al- mil, amlodipine/long acting formula- lergens, triggering production of IgE antibodies, tions only causing histamine release and subsequent edema, (a) Drug action—promote periph- itching, discharge, and sneezing eral arterial vasodilation, which decreases oxygen demand by de- • Etiology/Incidence creasing afterload, also decrease 1. Seasonal—occurs at specific times of year coronary vasospasm when pollens/allergens are present (hay fever) (b) Side-effects—hypotension, a. Trees—April to July edema, bradycardia, constipation, b. Grasses—May to July dizziness, headache, fatigue, nau- c. Ragweed—August to October sea, dyspnea, rash 2. Perennial—year-round symptoms usually (c) Drug interactions—may potenti- related to dust mites, mold, cockroaches, and ate beta blockers, other antihy- animal dander pertensives, digitalis; antagonized 3. Affects approximately 10% of adults; onset by rifampin, phenobarbital typically between ages 10–20 (d) Contraindications—severe left ventricular dysfunction, hypoten- • Signs and symptoms sion, heart block greater than one 1. Nasal congestion, clear rhinorrhea, sneezing degree, cardiogenic shock; preg- 2. Pruritus of nose, throat, eyes nancy category C 3. Sore throat and cough from postnasal drip (4) Long acting nitrates—nitropaste, ni- tropatches, isosorbide dinitrate • Physical findings (a) Drug action—cause venous dila- 1. Pale, boggy nasal mucosa tion, which decreases venous 2. Clear, thin rhinorrhea return to the heart and modest 3. Injected conjunctiva, tearing arterial vasodilation; results in 4. “Allergic shiners” or dark discoloration beneath both eyes 256 Chapter 8 Nongynecological Disorders/Problems Contraindications Pregnancy category B; caution nursing mothers Caution in patients with renal or hepatic dysfunction. Pregnancy categories B/C; not recommended while nursing Pregnancy category C; caution nursing mothers Severe hypertension or cardiovascular disease. Pregnancy category C; not recommended while nursing recommended while nursing Precautions for pregnancy/ nursing mothers Interactions Additive effects with alcohol, Additive effects sedatives, anti-anxiety agents Zyrtec—potentiates other CNS depressants Potentiates other CNS depressants Hypertensive crisis with MAO inhibitors Cytochrome P450 effect Pregnancy category C; not None known Side-effects Drowsiness, dry mucous membranes, blurred vision (with Fewer sedating effects exception of cetirizine) headache Increases heart rate and BP. CNS stimulation. Use with caution in hypertensive patients Local irritation, epistaxis, headache. Systemic absorption at recommended doses minimal Local reactions: burning, stinging, sneezing Action Block action of histamine; anticholinergic effects Selective peripheral histamine receptor antagonist; no anticholinergic effects Alpha-adrenergic agonists; vasoconstriction reduces engorgement of mucosa Anti-inflammatory effects; therapeutic benefit not immediate mast cells; prophylactic drug Antihistamines, Decongestants and Anti-inflammatory Medications for Respiratory Disorders (representative list) Drug Table 8-2 â Table Â Antihistamines 1st generation Chlorpheniramine (Chlor-Trimeton) Diphenhydramine (Benadryl) 2nd generation Loratidine (Claritin) Desloratidine (Clarinex) Fexofenadine (Allegra) Cetirizine (Zyrtec) Azelastine HCL (Astelin)Decongestants antihistamine Topical Pseudoephedrine Bitter taste, somnolence, Nasal corticosteroids Budesonide (Rhinocort) Fulticasone (Flonase) Mast cell stabilizers Cromolyn (Nasalcrom) Prevents degranulation of Eye, Ear, Nose, and Throat Disorders 257

• Differential diagnosis Conjunctivitis 1. Vasomotor rhinitis 2. Atrophic rhinitis • Definition—encompasses a broad group of 3. Secondary to selected medications—antihy- conditions presenting as inflammation of the pertensive agents conjunctiva 4. Rhinitis medicamentosa—excessive topical use of topical vasoconstrictors • Etiology/Incidence 5. Nasal polyps 1. Viral conjunctivitis—adenovirus most common; herpes simplex and herpes zoster • Diagnostic tests/findings 2. Bacterial conjunctivitis—Staphylococcus au- 1. Usually none indicated reus (adults), Streptococcus pneumoniae and 2. Nasal smear for eosinophils—eosinophils Haemophilus influenzae (children) present in 65–75% of cases 3. Allergy—type I, IgE mediated hypersensitivity 3. Skin tests to determine specific allergens; gold reaction precipitated by small airborne aller- standard test gens, e.g., pollen, animal dander, dust 4. In vitro serum allergy tests—RAST; expensive 4. Most common eye complaint in primary care and not as sensitive as specific skin testing • Signs and symptoms • Management/Treatment 1. Sensation of grit in eye, “scratchy”; mild 1. Nonpharmacologic—allergen avoidance discomfort a. Bedroom must be the most allergen free 2. Pain, photophobia, blurred vision that fails to b. Environmental control—vacuum, dust, clear with blink are not typical features of pri- remove carpeting, feather pillows, stuffed mary conjunctival process animals 3. Viral conjunctivitis c. Eliminate or restrict exposure to pets; pets a. Acute onset; may be unilateral or bilateral should not be in bedroom with a watery discharge d. Air conditioning/air filters b. Preauricular adenitis 2. Pharmacologic (see Table 8-2) c. May be associated with upper respiratory a. Antihistamines infection (1) Generally considered first line therapy 4. Bacterial conjunctivitis (2) Highly effective in reducing itching, a. Acute onset; symptoms begin in one eye sneezing, rhinorrhea; minimal effect and spread to other eye on nasal congestion b. Mucopurulent discharge; patient reports (3) More effective if given before onset of eyelids are matted together on awakening symptoms c. Marked conjunctival injection of abrupt b. Decongestants onset with copious purulent discharge as- c. Topical corticosteroids sociated with gonococcal infection; sight- (1) Given their effectiveness, increased threatening ocular infection use as first line treatment 5. Allergic conjunctivitis (2) Not helpful with ocular symptoms a. Major cause of chronic conjunctivitis (3) Slow onset of effect; must be used on b. Complaints of bilateral itching, tearing, regular basis to be effective redness, and mild eyelid swelling d. Mast cell stabilizers c. Discharge is clear and watery or stringy e. Montelukast (see Table 8-3) and mucoid 3. Patient education d. Personal or family history of atopic disease a. Identify and eliminate or avoid allergens, e.g., remove carpeting, pets, install air • Physical findings filters 1. Characterized by dilation of superficial con- b. Appropriate use of medications, combina- junctival blood vessels, resulting in hyperemia; tions, side-effects, and overuse syndromes hyperemia greatest at the periphery of the bul- bar conjunctiva • Referral—refer for skin tests to determine specific 2. Discharge (see Signs and symptoms) allergens 3. Cornea clear; PERRL 4. Visual acuity with no acute change 5. Preauricular adenopathy 258 Chapter 8 Nongynecological Disorders/Problems Precautions Contraindications/ Cardiovascular disease; pregnancy category C; not recommended for nursing mothers Not for treatment of acute attack; pregnancy category C; use caution with nursing mothers Systemic mycoses; live vaccination Should not be used for symptom relief or acute exacerbation; cardiovascular disease; pregnancy category C; not recommended for nursing mothers Interactions Cytochrome P450 effect; Cytochrome P450 effect; caution with CYP3A4 inhibitors, e.g., ketoconazole NSAIDs MAO inhibitors, tricyclic antidepressants, sympathomimetic agents; antagonized by beta- blockers MAO inhibitors, tricyclic antidepressants, sympathomimetic agents; antagonized by beta- blockers Side-effects Minimal systemic effects; Minimal systemic effects; oropharyngeal candidiasis, dysphonia Adrenal suppression; masks infection Tachycardia, nervousness, Tachycardia, skeletal muscle tremor Headache, pharyngitis, URI, tachycardia, tremor Action -receptors -receptors 2 2 Relaxes bronchial smooth muscle by selective action on B muscle by selective action on B Inhibits inflammatory response -agonists -agonists 2 2 Asthma Quick-Relief and Long-Term-Control Medications (representative list) Asthma Quick-Relief and Long-Term-Control Drug Table 8-3 â Table Â Short acting inhaled B Albuterol (MDI and Nebulizer soln) Salmeterol DPI (Diskus) Relaxes bronchial smooth Inhaled corticosteroids Fluticasone MDI/DPI* Budesonide DPI Oral steroids Prednisone Long acting inhaled B Eye, Ear, Nose, and Throat Disorders 259 Not for treatment of acute attack; pregnancy category C; use caution with nursing mothers Pregnancy category B; use caution with nursing others Not for treatment of acute attacks; pregnancy category B; caution with nursing mothers Peptic ulcer disease, arrhythmias, seizure disorders; pregnancy category C; not recommended for nursing mothers MAO inhibitors, tricyclic antidepressants, sympathomimetic agents; antagonized by beta- blockers Monitor with drugs that induce Cytochrome P450 enzymes, e.g., rifampin None identified Cytochrome P450 effect; numerous drugs may effect serum concentration via induction or inhibition of P450 enzymes Respiratory tract infection, laryngeal spasm/swelling, headache, hoarseness GI Headache, fatigue, fever, upset Bronchospasm, throat irritation, bad taste, cough GI upset, headache, CNS stimulation, diuresis, arrhythmias, seizures broncho-dilating effects Leukotriene receptor antagonist of histamine, leukotrienes, slow-reacting substance of anaphylaxis Relaxes bronchial smooth muscle Combined medication Fluticasone (Salmeterol)anti-inflammatory/ Combined Leukotriene modifiers Montelukast Mast cell stabilizers Cromolyn (Nedocromil) Prevents mast cell release Methylxanthines Theophylline *Metered-dose inhaler/Dry-powdered inhaler 260 Chapter 8 Nongynecological Disorders/Problems

• Differential diagnosis b. Common pathogens—Streptococcus pneu- 1. Foreign body moniae, Haemophilus influenzae, Mo- 2. Subconjunctival hemorrhage raxella catarrhalis, viruses 3. Blepharitis 2. Highest incidence in childhood, younger than 4. Episceritis/scleritis age 10 5. Keratitis 3. Risk factors 6. Uveitis a. Recent/current URI 7. Acute angle closure glaucoma b. Exposure to cigarette smoke, active or passive • Diagnostic tests/findings 1. Fluorescein stain—stain uptake suggests cor- • Signs and symptoms neal involvement 1. Ear pain, decreased hearing, fever 2. Diagnostic testing if gonococcal, chlamydial 2. Aural pressure infection, chronic or recurrent infection sus- 3. Vertigo, nausea and vomiting pected, or failure to respond to treatment • Physical findings • Management/Treatment 1. Full or bulging tympanic membrane (TM) with 1. Viral absent or obscured landmarks a. Self-limited; topical antibiotics often 2. Distorted light reflex prescribed 3. Decreased/absent mobility of TM on pneu- b. Avoid touching eyes; avoid close contact matic otoscopy for approximately 2 weeks 4. Erythema of TM is an inconsistent finding 2. Bacterial 5. Bullae on TM; often associated with Myco- a. Broad spectrum topical antibiotic—so- plasma pneumoniae dium sulfacetamide (Sulymid); polymixin 6. Preauricular or cervical lymphadenopathy B/trimethoprim (Polytrim); tobramycin (Tobrex) • Differential diagnosis b. Reserve fluoroquinolones for severe 1. Otitis externa infections 2. Otitis media with effusion 3. Allergic 3. Temporomandibular joint (TMJ) syndrome a. Removal of offending allergen if possible 4. Dental abscess b. Topical antihistamine—levocabastine 5. Mastoiditis (Livostin) c. Mast cell stabilizer—cromolyn (Crolom) • Diagnostic tests/findings d. Mast cell stabilizer/antihistamine—olopa- 1. Usually none indicated tadine HCL (Patanol) 2. Tympanometry for recurrent infections; indi- e. Topical NSAIDs—ketorolac (Acular) cator fluid posterior to TM

• Referral • Management/Treatment 1. Patients with pain, photophobia, blurred vi- 1. Pharmacologic sion; circumcorneal erythema/ciliary flush a. Antibiotics 2. No improvement after 48 hours of treatment (1) Amoxicillin; for penicillin- allergic patients, trimethoprim/ Acute Otitis Media sulfamethoxazole or erythromycin; if inadequate response, change to • Definition—infection of the middle ear that is amoxicillin-clavulanate often preceded by upper respiratory infection or (2) Side-effects allergies (a) GI upset, nausea, vomiting, diarrhea • Etiology/Incidence/Risk factors (b) Rashes, urticaria 1. Etiology (3) Drug interactions—trimethoprim/ a. Eustachian tube dysfunction second- sulfamethoxazole may potentiate oral ary to URI or allergies causes edema and anticoagulants, hypoglycemics congestion that impedes flow of middle (4) Contraindications/precautions ear secretions; accumulation of secretions (a) Hepatic impairment promotes growth of pathogens Eye, Ear, Nose, and Throat Disorders 261

(b) Pregnancy category B except sulfa 3. Recurrent infections; patient may require con- drugs, which are category C; sulfa sideration for myringotomy not recommended while nursing b. No demonstrated benefit with use of Sinusitis decongestants c. Analgesics/antipyretics • Definition—inflammation of the mucosal surface (1) Acetaminophen of the paranasal sinuses (a) Drug action—inhibits CNS prostaglandin synthesis • Etiology/Incidence (b) Side-effects—can cause serious or 1. Etiology fatal hepatic injury a. Acute sinusitis—caused by viral or bac- (c) Drug interactions—increased risk terial infections and allergies; bacterial of hepatotoxicity with chronic, causes include Streptococcus pneumo- heavy alcohol use niae, Haemophilus influenzae, Moraxella (d) Contraindications/precautions— catarrhalis pregnancy category B; use with b. Infection usually involves maxillary and caution while nursing ethmoid sinuses (2) Nonsteroidal anti-inflammatory drugs c. Chronic sinusitis occurs with episodes of (NSAIDs) prolonged infection that resist treatment (a) Ibuprofen, naproxen, ketoprofen and/or repeated or inadequately treated (b) Drug action acute infection; treatment failure second- i. Inhibits cyclooxygenase, ary to failure of sinuses to drain, which the enzyme that catalyzes may be associated with anatomic defect the synthesis of prostaglan- 2. Incidence–accounts for 6% of primary care of- dins and thromboxane from fice visits arachidonic acid ii. Analgesic, anti-inflammatory • Signs and symptoms and antipyretic effects 1. Acute sinusitis (c) Side-effects a. Nasal congestion, facial pain, toothache, i. Hypersensitivity headache, fever, yellow/green nasal ii. Dyspepsia, GI bleeding drainage iii. Tinnitus, drowsiness, b. Increased pain with bending over or sud- headache den head movement iv. Nephrotoxiciy c. Common cold and allergic/vasomotor v. Hepatotoxicity rhinitis may precede infection (d) Interactions d. “Double sickening”—URI symptoms with i. Decreased antihypertensive initial improvement followed by increas- effect of ACE inhibitors, beta- ing nasal symptoms blockers, diuretics 2. Chronic sinusitis ii. Potentiates anticoagulants a. Nasal congestion, discharge, and cough (e) Contraindications/precautions that last longer than 30 days i. Aspirin allergy b. Dull ache or pressure across forehead ii. Pregnancy C, but contraindi- and/or midface cated in third trimester; not c. Constant postnasal drip and chronic recommended while nursing cough 2. Patient education a. Appropriate ear canal hygiene • Physical findings b. Antibiotic use and side-effects 1. Afebrile or low-grade fever c. Need for additional care if no improve- 2. Mucopurulent nasal discharge; postnasal ment in 2 to 3 days discharge 3. Nasal mucosa swollen, pale, dull red to gray • Referral 4. Pain on firm palpation over sinus areas 1. For suspected extension of infection, mastoiditis, or perforation of tympanic membrane • Differential diagnosis 2. Persistent hearing loss after adequate 1. Uncomplicated URI treatment 2. Migraine headaches 3. Allergic/vasomotor rhinitis 262 Chapter 8 Nongynecological Disorders/Problems

4. Nasal polyps Common Cold 5. Dental abscess • Definition—an acute, mild, self-limited viral infec- • Diagnostic tests/findings tion of the upper respiratory tract mucosa 1. None for typical presentation 2. Sinus radiography • Etiology/Incidence/Risk factors a. Confirmed by mucosal thickening, sinus 1. Etiology opacity, air–fluid levels a. Inflammation of the mucosal membranes b. Normal sinus radiography to exclude from the nasal mucosa to the bronchi maxillary and frontal disease; ethmoid in- b. Rhinovirus, coronavirus, adenovirus volvement more difficult to exclude c. Spread by airborne droplets and contact 3. CT scan—reserved for complicated disease with infectious secretions on hands and and search for ethmoidal disease in patients environmental surfaces with refractory symptoms and negative con- d. Incubation period 48–72 hours ventional radiographs 2. Incidence a. Peaks in winter months • Management/Treatment b. Children—6 to 8 infections per season 1. Nonpharmacologic c. Adults—2 to 4 per season a. Saline nasal spray 3. Risks b. Steam inhalation a. Repeated exposure to groups of children c. Warm compresses b. Close quarters, contact d. Hydration—2000 to 3000 mL daily 2. Pharmacologic • Signs and symptoms a. Antibiotics (see Acute Otitis Media this 1. General malaise chapter) 2. Nasal congestion and clear rhinorrhea (1) If signs and symptoms are present 10 3. Sneezing, coughing, sore throat, hoarseness or more days after onset of upper 4. Tearing, burning sensation of eyes respiratory symptoms (2) If signs and symptoms of acute • Physical findings sinusitis worsen with 10 days of initial 1. Low-grade fever improvement 2. Nasal mucosa swollen and erythematous b. Oral/topical decongestants 3. Conjunctiva slightly red (1) Oral decongestants (see Table 8-2) 4. Throat erythematous with cervical (2) Topical decongestant/oxymetazoline lymphadennopathy spray 0.05% (a) Provides rapid relief • Differential diagnosis (b) Should not be used for longer 1. Allergic rhinitis than 3–5 days to prevent rebound 2. Streptococcal pharyngitis congestion 3. Influenza c. Nasal steroids—to reduce mucosal inflam- 4. Otitis media mation (see Table 8-2) d. Antihistamines not recommended unless • Diagnostic tests/findings patient has allergies 1. Generally none recommended e. Pain management as needed with aceta- 2. Rapid strep screen/throat culture if strepto- minophen, NSAIDS, opioids if severe coccal pharyngitis suspected 3. Patient education a. Avoidance of allergens, environmental ir- • Management/Treatment ritants, e.g., cigarette smoke 1. Nonpharmacologic b. Importance of maintaining adequate a. Inhalation of warm vapors hydration b. Saline nasal drops or sprays c. Saline gargles/throat lozenges • Referral d. Increase fluids 1. Severe facial pain, periorbital swelling 2. Pharmacologic 2. Failure to respond to two courses of antibiotic a. Acetaminophen or NSAIDs (see Acute Oti- 3. Suspected anatomic abnormality tis Media this chapter) 4. Chronic sinusitis or more than three episodes b. Topical/oral decongestants (see Table 8-2) of acute sinusitis per year Eye, Ear, Nose, and Throat Disorders 263

c. Cough suppressants—e.g., a. Sore throat, fever, malaise, cough, head- dextromethorphan ache, myalgias, and fatigue (1) Drug action—depresses cough reflex b. May also complain of rhinitis, congestion, by direct inhibition of cough center in conjunctivitis the medulla 2. GABHS (2) Side-effects—minimal CNS depres- a. Sudden onset of sore throat, fever, chills, sant action headache, nausea/vomiting (3) Drug interactions—hyperpyretic crisis b. Rhinitis, cough, conjunctivitis not typi- with MAOIs cally present (4) Contraindications/precautions (a) Persistent or chronic cough • Physical findings (b) First trimester of pregnancy; cau- 1. Viral pharyngitis—mild erythema of the phar- tion while nursing ynx with little or no exudates d. Expectorants—e.g., guaifenesin 2. Bacterial pharyngitis (1) Drug action—may increase output of a. Marked erythema of the throat, exudates, respiratory tract secretions facilitating tender anterior cervical lymphadenopathy removal of mucus b. Erythematous “sandpaper” rash/ (2) Side-effects—GI upset, drowsiness, accentuation in groin and axillae with headache scarlet fever (3) Drug interactions—may increase toxicity/effect of disulfiram, MAOIs, • Differential diagnosis metronidazole, procarbazine 1. Peritonsillar abscess (4) Contraindications/precautions— 2. Infectious mononucleosis pregnancy category C; use with cau- 3. Pharyngeal candidiasis tion while nursing 4. Diphtheria 3. Patient education 5. Epiglottitis a. Infection control b. Self-limited nature of infection • Diagnostic tests/findings c. Symptoms of complications; secondary 1. Rapid strep antigen test—detects only GABHS bacterial infection (5–10% false negatives); throat culture if negative rapid strep test Pharyngitis 2. Throat culture for suspected gonococcal infection • Definition—inflammation of the pharynx and tonsils • Management/Treatment 1. Nonpharmacologic • Etiology/Incidence a. Adequate hydration 1. Etiology b. Saline gargles a. Viral—most common cause is rhinovirus c. Topical anesthetics, e.g., lozenges, sprays and adenovirus 2. Pharmacologic b. Bacterial a. GABHS (1) Group A b-hemolytic streptococci (1) Penicillin V PO/benzathine pencillin (GABHS) IM (2) Neisseria gonorrhea (a) Drug action—bactericidal c. Noninfectious causes—allergic rhinitis or (b) Side-effects—hypersensitivity postnasal drip reactions 2. Incidence (c) Contraindications/precautions— a. One of the most frequent reasons for out- penicillin allergy; pregnancy cat- patient care in US egory B b. Accounts for 16 million office visits (2) Erythromycin if penicillin allergy per year; 2.5% of visits to primary care b. Gonococcal pharyngitis—Ceftriaxone IM providers (1) Drug action—bactericidal (2) Side-effects—injection site reaction, • Risks—crowded work or living conditions hypersensitivity reactions (3) Drug interactions—potentiated by • Signs and symptoms probenecid 1. Viral pharyngitis (4) Contraindications/precautions—penicillin allergy; pregnancy category B 264 Chapter 8 Nongynecological Disorders/Problems

(5) Alternative agents—azithromycin, • Management/Treatment spectinomycin—obtain pharyngeal 1. Nonpharmacologic—lozenges, gargles culture 3–5 days after treatment if use for relief of pharyngitis; treatment largely alternative regimen supportive 2. Pharmacologic • Referral a. Fever—acetaminophen, NSAIDs to reduce 1. Suspected peritonsillar abscess fever, aches (see Acute Otitis Media this 2. Epiglottitis chapter) b. Corticosteroids—prescribed for significant Infectious Mononucleosis (IM) pharyngeal edema and obstructive tonsillar enlargement • Definition—an acute viral syndrome secondary to 3. Patient education Epstein-Barr virus characterized by fever, pharyn- a. Rest during acute phase of illness; activity gitis, and lymphadenopathy as tolerated b. Contact sports, heavy lifting, and strenu- • Etiology/Incidence ous activity should be avoided for at least 1. Etiology 1 month a. Causal agent is Epstein-Barr virus (EBV) c. Avoid alcohol for at least 1 month b. Mode of transmission is oropharyngeal d. Seek immediate care with sudden onset of route via saliva severe abdominal pain 2. Incidence—rarely symptomatic in children younger than 5 years; most clinically apparent • Referral infections occur in individuals 10–35 years old 1. Onset of abdominal pain—possible ruptured spleen • Signs and symptoms 2. Airway obstruction from pharyngeal edema 1. Prodrome of headache, malaise, fatigue, anorexia Â Lower Respiratory Disorders 2. Fever, sore throat, swollen lymph nodes Community-Acquired Pneumonia • Physical findings 1. Tonsillar enlargement with exudate • Definition—acute infection of the lower respira- 2. Palatal petecchiae at junction of hard and soft tory tract that is associated with symptoms of palates (25% of cases) acute infection, altered breath sounds or rales on 3. Lymphadenopathy; particularly posterior physical examination and acute infiltrate on chest cervical radiograph in a patient who has not been hospital- 4. Fever compatible with severity of infection ized or resided in a long-term care facility for 14 5. Hepatomegaly (25% cases) days before the onset of symptoms. 6. Splenomegaly (50% cases) • Etiology/Incidence/Risk factors • Differential diagnosis 1. Etiology 1. Streptococcal pharyngitis a. Bacterial—Streptococcus pneumoniae, 2. Other viral causes of pharyngitis Haemophilus influenzae, Legionella 3. Hepatitis pneumophila 4. HIV infection b. Nonbacterial—Mycoplasma pneumoniae, Chlamydia pneumoniae • Diagnostic tests/findings c. Viral—Influenza, adenovirus 1. Monospot/heterophile antibody test 2. Incidence—sixth leading cause of death; lead- a. Up to 86% specific; 99% sensitive ing cause of death from infectious disease b. Initially negative, usually positive by 1 to 2 3. Risk factors weeks after onset of symptoms a. Preceding viral URI 2. CBC—lymphocytic leukocytosis with 10% of b. Cigarette smoking cells atypical c. Age older than 50 3. Elevated aminotransferases (AST, ALT), d. Chronic lung disease bilirubin e. Corticosteroid use 4. Throat culture—frequent secondary infection f. Immunosuppression with GABHS Lower Respiratory Disorders 265

• Signs and symptoms 2. Pharmacologic 1. May be masked or absent in very young, el- a. Empiric antimicrobial therapy derly, immunosuppressed, coexisting chronic (1) Patients without comorbidity and disease less than 60 years—azithromycin or 2. Fever, chills, sweats clarithromycin 3. Cough with/without sputum production (a) Drug action—inhibits bacterial 4. Dyspnea, pleuritic chest pain protein synthesis 5. Associated symptoms—lethargy, headache, (b) Side-effects—GI effects anorexia, nausea, vomiting (c) Drug interactions—inhibits cytochrome P450 enzymes; may • Physical findings inhibit metabolism of other drugs 1. Tachycardia (d) Contraindications/precautions— 2. Tachypnea, dyspnea hypersensitivity to macrolide 3. Percussion antibiotics; pregnancy category B; a. Often normal in early disease enters human milk/use caution b. Dullness over area of consolidation (e) Alternative agents include doxy- 4. Auscultation cycline, levofloxacin a. Coarse rhonchi may clear or shift with (2) Patients with comorbidity or over 60 cough years—levofloxacin b. Nonclearing rales (a) Drug action—inhibits bacterial c. Diminished breath sounds over DNA synthesis consolidation (b) Side-effects—GI upset, CNS 5. Fever with chills, high spikes (102.2°F or above) toxicity especially if bacterial etiology (c) Drug interactions—avoid drugs 6. Small areas of pneumonia cannot always be that prolong QT interval; in- detected by physical examination creased risk of tendon rupture with corticosteroids; inhibits • Differential diagnosis cytochrome P450 enzymes; may 1. Bronchitis inhibit metabolism of other drugs 2. Atelectasis (d) Contraindications/precautions— 3. Chronic obstructive pulmonary disease pregnancy category C; not recom- 4. Congestive heart failure mended for nursing mothers 5. Malignancy (e) Alternative agents include beta- 6. Tuberculosis lactam/macrolide combination 7. Pulmonary embolism b. Antipyretics—acetaminophen, NSAIDs (see Acute Otitis Media this chapter) • Diagnostic tests/findings 3. Patient education 1. Chest radiograph a. Infection containment principles a. Establishes diagnosis by revealing an infil- b. Need for hydration trate; helps distinguish pneumonia from c. Rest acute bronchitis d. Increased caloric requirements with fever b. Demonstrates the presence of complica- e. Medication schedules and side-effects tions such as pleural effusion and multilo- bar disease • Referral/MD consult 2. Value of sputum collection for Gram’s stain 1. Base decision to hospitalize on age, comorbid and culture is controversial illness, physical examination, and laboratory 3. CBC with differential—white blood cell (WBC) findings elevation (10,000/mm3 to 25,000/mm3) with a 2. No improvement in 24 to 36 hours shift to left, e.g., bandemia, neutrophilia, espe- 3. Fever over 102°F, pallor or cyanosis, nasal cially if bacterial etiology flaring 4. Mental confusion • Management/Treatment 1. Nonpharmacologic Asthma a. Oral hydration and humidification b. Improve oxygenation, e.g., smoking • Definition cessation 1. A chronic inflammatory disorder of the airways in which many cells and cellular 266 Chapter 8 Nongynecological Disorders/Problems

elements play a role, in particular, mast cells, related to allergens, but nonallergic trig- eosinophils, T lymphocytes, neutrophils, and gers likely to be a factor epithelial cells; in susceptible individuals, 2. Incidence this inflammation causes recurrent episodes a. Occurs in approximately 3% of the general of wheezing, breathlessness, chest tightness population and cough, particularly at night and the early (1) Affects approximately 10% of children morning; these episodes are associated with (2) Affects approximately 5% of adults airflow obstruction that is often reversible; the b. Can occur at any age; increasing in preva- inflammation also causes an associated in- lence in US crease in existing bronchial hyperresponsive- ness to a variety of stimuli (NHLBI, 2007) • Signs and symptoms 2. Classification correlates to treatment 1. Episodic wheeze, chest tightness, shortness of recommendations breath or cough; cough may be sole symptom a. Intermittent—step 1 2. Symptoms worsen in presence of aeroaller- (1) Symptoms 2 times/week or less; noc- gens, irritants, and exercise turnal symptoms 2 times/month or 3. Symptoms occur or worsen at night; cause less nighttime awakening

(2) PEF/FEV1 greater than 80% of pre- 4. History of allergic rhinitis or atopic dermatitis; dicted value; variability less than 20%; family history of asthma, allergic rhinitis or normal between exacerbations atopic dermatitis b. Mild persistent—step 2 (1) Symptoms 3–6 times/week; nocturnal • Physical findings symptoms 3–4 times/month 1. Hyperexpansion of thorax; hyperresonance

(2) PEF/FEV1 greater than 80% of pre- with percussion dicted value; variability 20–30% 2. Wheezing; prolonged expiratory phase c. Moderate persistent—step 3 3. Diminished breath sounds (1) Daily symptoms; nocturnal symp- 4. Tachypnea, dyspnea toms more than 1 time/week but not 5. Atopic dermatitis/eczema or other skin mani- nightly festations of allergic skin disorders

(2) PEF/FEV1 greater than 60% but less 6. Increased nasal secretions, mucosal swelling, than 80%; variability greater than 30% nasal polyps d. Severe persistent—step 4 (1) Continual daily symptoms; frequent • Differential diagnosis nocturnal symptoms 1. Acute infection—bronchitis, pneumonia

(2) PEF/FEV1 less than 60%; variability 2. Chronic obstructive pulmonary disease greater than 30% (COPD); may overlap with asthma 3. Heart disease—heart failure • Etiology/Incidence 4. Foreign body aspiration 1. Etiology 5. Pulmonary emboli a. Caused by single or multiple triggers 6. Cough secondary to drugs such as ACE (1) Allergic triggers inhibitors (a) Airborn pollens, molds, dust mites, cockroaches, animal • Diagnostic tests/findings dander 1. Pulmonary function tests/spirometry—to es- (b) Food additives or preservatives tablish airway obstruction

(2) Nonallergic triggers ond) less than 80% of predicted; FEV1/FVC (a) Smoke and other pollutants (forced vital capacity) less than 65% or be- (b) Viral respiratory infections low limit of normal (c) Medications—ASA, NSAIDs, beta- b. Spirometry and peak flow rates improve

blockers with bronchodilator challenge; FEV1 in- (d) Exercise creases 12% and at least 200 mL after use

(e) Gastroesophageal reflux of inhaled short acting B2-agonist (f) Emotional factors 2. If normal spirometry, assess diurnal variation (g) Menses, pregnancy in PEF (peak expiratory flow); 20% difference b. In children there is generally a strong his- between two measures/PEF variability sup- tory of atopy; adult-onset asthma may be ports diagnosis of asthma Lower Respiratory Disorders 267

3. Bronchoprovocation with methacholine, hista- (1) High-dose inhaled corticosteroids and

mine, or exercise if diagnosis in question; neg- long acting inhaled B2-agonist; oral ative test helps exclude diagnosis of asthma corticosteroid if needed

4. Chest radiograph if infection, large airway le- (2) Short acting inhaled B2-agonist as sions, heart disease, or foreign body obstruc- needed for symptoms tion suspected e. Severe exacerbation (peak flow < 60%) can occur with any category of asthma; con- • Management/Treatment sider short course of oral steroids 40–60 1. Goals mg/d for 5–10 days (NHLBI, 2007) a. Minimize symptoms, normalize daily 4. Patient education activity a. How to recognize signs of worsening b. Maintain near-normal pulmonary asthma function b. Use of peak flow meter

c. Minimal use of short acting B2-agonist c. Clear instructions on use of written 2. Nonpharmacologic “Asthma Action Plan” a. Peak flow monitoring d. Proper use of inhaler for effective dosing (1) Establish patient’s “personal best” and e. Prophylactic medication, e.g., pre-exercise develop “Asthma Action Plan” dosing (2) A drop in peak flow below 80% indi- f. Control of environmental factors, e.g., al- cates an acute exacerbation and need lergens and irritants to contact clinician for medication adjustment • Referral (3) A drop in peak flow below 50% indi- 1. Failure to respond to emergency treatment; cates need for emergency treatment arrange for emergency room treatment if signs b. Avoidance of known allergens, triggers of severe obstruction present—peak flow re- c. Adequate hydration and humidity duced by 50%, pulsus paradoxus, use of acces- d. Annual influenza vaccine and pneumo- sory muscles of respiration coccal vaccine 2. Difficulty controlling asthma or if step 4 is 3. Pharmacologic—stepwise approach (see required Table 8-3) a. Intermittent—step 1 Tuberculosis (TB) (1) No daily medications

(2) Short acting inhaled B2-agonist as • Definition—necrotizing bacterial infection caused needed for symptoms by Mycobacterium tuberculosis; most commonly (3) Course of systemic corticoste- infects the lungs, but any organ can be affected roids recommended for severe 1. Active TB disease/ATBD—signs, symptoms, exacerbations and radiographic findings secondary to b. Mild persistent—step 2 M. tuberculosis; disease may be pulmonary (1) Low-dose inhaled corticosteroids or extrapulmonary (2) Alternative treatments—mast-cell 2. TB infection/Latent TB infection (LTBI) stabilizer, leukotriene modifier, or a. Positive tuberculin skin test with no signs theophylline or symptoms of disease

(3) Short acting inhaled B2-agonist as b. Chest radiograph negative or only needed for symptoms granulomas/calcifications in lungs c. Moderate persistent—step 3 and/or regional lymph nodes (1) Low-medium dose inhaled corticosteroids and long acting inhaled • Etiology/Incidence/Risk factors

B2-agonist 1. Etiology—Mycobacterium tuberculosis; spread (2) Alternative treatments: add leuko- by small airborne particles triene or theophylline; increase in- 2. Incidence haled corticosteroid within medium a. 10 to 15 million infected in US; 90–95% of dose range primary TB infections remain in a latent or

(3) Short acting inhaled B2-agonist as dormant stage needed for symptoms b. Incidence rising due to HIV infection d. Severe persistent—step 4 3. Risk factors a. HIV-infected individuals 268 Chapter 8 Nongynecological Disorders/Problems

b. Incarceration, crowding, or institutional (a) HIV infection, living immunocompromised/ c. Intravenous drug use, alcoholism immunosuppressed individuals d. Racial or ethnic groups at risk—Hispanic, (b) Those with abnormal chest radio- Native American, African American graphs consistent with healed TB e. Healthcare workers in hospitals, clin- lesions ics, daycare, long-term care, correctional (c) Recent close contact with infected facilities person f. Household contacts of diagnosed cases (2) A reaction of 10 mm or greater is considered positive among • Signs and symptoms (a) Recent arrivals (< 5 years) from 1. TB infection/LTBI high prevalence areas a. Asymptomatic state may last months to (b) Low socioeconomic status, years homeless b. 10% go on to develop active TB (c) Aged, nursing home resident, in- 2. Active TB/ATBD carcerated individual a. Generalized symptoms (d) Individuals with chronic disease (1) Night sweats, fever or predisposing conditions, e.g. (2) Malaise, weakness gastrectomy, diabetes mellitus, or (3) Anorexia corticosteroid therapy (4) Weight loss (3) A reaction of 15 mm or greater is con- b. Pulmonary symptoms sidered positive among individuals (1) Productive cough, possible without risk factors hemoptysis c. False-negative (2) Chest pain (1) PPD administered after live virus (3) Dyspnea vaccine c. Systemic symptoms (extrapulmonary (2) Immunosuppressed sites) (3) Elderly (1) Pelvic pain d. False-positive (2) Flank pain (1) Recent BCG vaccine (2) Nontuberculosis mycobacterium • Physical findings e. “Positive converter”—previous negative 1. Generally normal appearance in early disease, PPD progressing to cachectic 2. QuantiFERON-TB Gold blood test also used 2. Unexplained fever for routine screening 3. Lung findings—increased tactile fremitus and a. Less false positives than skin test dullness to percussion over consolidated ar- b. More convenient—1 office visit, results eas; apical rales and whispered pectoriloquy within 24 hrs 4. Advanced disease—purulent green or yellow c. Not affected by prior BCG vaccination sputum d. Some follow-up as for positive skin test 5. Hemoptysis e. More expensive 3. Chest radiography, both antero-posterior • Differential diagnosis and lateral views, indicated with positive PPD 1. Pneumonia result 2. Malignancy a. Identifies active pulmonary disease; nega- 3. Chronic obstructive pulmonary disease tive chest radiograph rules out active TB 4. Silicosis b. Radiologic findings include apical scar- 5. Sarcoidosis ring, hilar adenopathy with peripheral infiltrate and upper lobe cavitation • Diagnostic tests/findings 4. Three sputum samples required for both 1. Purified protein derivative (PPD) skin test smear and culture in patients suspected of (antigen response) recommended for routine pulmonary TB screening of individuals at risk of infection a. A presumptive diagnosis of TB can be a. Positive test indicates exposure, not active made with detection of acid-fast bacilli in disease sputum smear b. PPD interpretation b. A positive culture for M. tuberculosis is es- (1) A reaction of 5 mm or greater is con- sential to confirm diagnosis sidered positive in patients with Gastrointestinal Disorders 269

• Management/Treatment (2) Outdoor exercise 1. LTBI b. Pharmacologic a. Nonpharmacologic—not applicable (1) Typical regimen includes isoniazid, b. Pharmacologic rifampin, pyrazinamide for 2 months; (1) Treatment goal—stop progression to isoniazid and rifampin for 4 months; active disease state given resistance concerns include (2) Recommended for individuals at high ethambutol in initial regimen until risk of exposure and those at high risk drug susceptibility tests are known of progression from latent TB infec- (2) Directly observed therapy (DOT) is tion to active disease one method to ensure compliance; (a) Close contact of confirmed active healthcare provider/designee ob- TB serves patient ingest medications (b) Foreign-born persons from en- 3. Patient education demic countries and in US for 5 a. Importance of continuous treatment years or less (1) Possibility of microbial resistance (c) Residents and employees of con- (2) Signs of developing side-effects, drug gregate settings interactions (d) Healthcare workers with high-risk b. Infection control principles patients (1) Reducing respiratory droplet (e) Persons with HIV or otherwise broadcast immunosuppressed (2) Care with disposal of infected wastes, (f) Others on a case-by-case basis tissues assessment of risk for developing (3) Avoiding crowded conditions, contact active disease with susceptible individuals while (3) Screening procedures to identify ap- infectious propriate individuals for preventive c. Follow-up requirements, liver function treatment monitoring (a) Exclude active disease with chest d. Necessity for contact evaluation and radiograph treatment (b) Exclude individuals who have al- e. Importance of general health ready been adequately treated maintenance (c) Identify contraindications to isoniazid • Referral (d) Identify individuals needing spe- 1. Patients with ATBD cial consideration, e.g., pregnant, 2. Report all cases to health department for mon- older than 35 itoring, strain identification (4) Treatment with isoniazid for 9 months 3. Health department follow-up for contact trac- (a) Drug action—inhibition of myo- ing, risk assessment colic acid synthesis resulting in disruption of bacterial cell wall Â Gastrointestinal Disorders (b) Side-effects—GI symptoms; hepatitis/monitor transaminase Constipation levels at baseline, 3, 6, and 9 mos; peripheral neuropathy/dose with • Definition—constipation is a symptom rather than a disease vitamin B6 (pyridoxine) (c) Drug interactions—alcohol in- 1. Decreased frequency of defecation creases risk of hepatitis; pyridox- 2. May also include complaints of straining at ine deficiency increases risk of stool, hard or small stools, sense of incom- peripheral neuropathy plete evacuation, abdominal pain or bloating, (d) Drug contraindications/ or need for digital manipulation to enable precautions—acute hepatic dis- defecation ease; pregnancy category C 2. Active disease treatment—consult/referral to • Etiology/Incidence specialist 1. Etiology a. Nonpharmacologic a. Functional causes—low-fiber diet, motil- (1) Well-balanced diet; additional caloric ity disorders (irritable bowel syndrome), intake may be needed to maintain or sedentary life style, dehydration gain weight 270 Chapter 8 Nongynecological Disorders/Problems

b. Structural abnormalities—anal disorders • Management/Treatment (anal fissure), colonic mass with obstruc- 1. Nonpharmacologic tion (adenocarcinoma) a. Increased fluid intake c. Systemic disease or condition—hypothy- b. Exercise roidism, pregnancy c. High-fiber diet—bran, fruits, vegetables, d. Neurologic, neuromuscular disorder— whole grain cereals and bread multiple sclerosis, spinal cord disorders 2. Pharmacologic e. Psychogenic disorders—depression a. Bulk-forming agents—psyllium husk, f. Medications—laxative overuse, anti- methylcellulose, calcium polycarbophil cholinergics, narcotics, calcium channel (1) Drug action blockers (a) Increased stool bulk, retention of 2. Prevalence—unknown due to frequent self- stool water, reduces transit time treatment; commonly reported by patients, (b) Used to prevent constipation, especially elderly not useful treatment of acute 3. Risks constipation a. Female gender/pregnancy (2) Side-effects b. Older age (a) Must be taken with ample fluid c. Low-fiber diet to prevent esophageal/intestinal d. Immobility obstruction or fecal impaction (b) Abdominal distention and flatus • Signs and symptoms (3) Drug interactions—decreased absorp- 1. Typically fewer than three bowel movements tion of digitalis, salicylates, tetracy- per week clines, nitrofurantoin, and others 2. Hard feces, difficult to pass (4) Contraindications/precautions 3. Abdominal bloating or pain (a) Signs of fecal impaction 4. Hemorrhoids (b) GI obstruction (c) Pregnancy category B • Physical findings b. Stool softeners—docusate sodium 1. Firm-to-hard stool in rectum (1) Drug action 2. Fecal impaction (a) Act as surfactants; lower surface 3. Abdomen tension, which facilitates penetra- a. Normal bowel sounds tion of water into stool b. Nontender with simple constipation (b) Useful for patients complaining of hard stools and those for • Differential diagnosis (see also Etiology) whom straining at stool should be 1. Irritable bowel syndrome avoided 2. Obstruction (2) Side-effects 3. Chronic/systemic disease (a) Bitter taste, throat irritation 4. Medication/drug use (b) Mild abdominal cramping, diarrhea • Diagnostic tests/findings—indicated when “red (3) Drug interactions—may increase ab- flags” identified, constipation is persistent or fails sorption of mineral oil to respond to treatment, or particular disorder (4) Contraindications/precautions suspected (a) Acute abdominal pain, intestinal 1. Red flags obstruction a. Abdominal pain, nausea/vomiting (b) Pregnancy category C b. Weight loss (c) Because absorption minimal, c. Melena, rectal bleeding should pose no risk to breast- d. Rectal pain feeding infant e. Fever c. Hyperosmolar laxatives—sorbitol, lactu- f. New onset over age 50 lose, polyethylene glycol 2. Diagnostic tests (1) Drug action a. CBC, TSH, glucose (a) Nonabsorbable disaccharide that b. Stools for hemoccult acts as osmotic diuretic c. Flexible sigmoidoscopy/colonoscopy (b) Drug of choice after bulk forming laxatives for chronic constipation Gastrointestinal Disorders 271

(2) Side-effects (3) Protozoa—Giardia lamblia, (a) Flatulence E. histolytica (b) Intestinal cramps, diarrhea (4) Bacterial toxins—Staphylococcus, (3) Drug interactions—antacids Clostridium (4) Contraindications/precautions (5) Medications—antibiotics, laxatives, (a) Acute surgical abdomen, intesti- antacids, alcohol nal obstruction, fecal impaction b. Chronic or recurrent (b) Galactose restricted diets (1) Protozoa—Giradia lamblia, (c) Pregnancy category B; caution in E. histolytica nursing mothers (2) Inflammatory—ulcerative colitis, d. Saline laxatives—magnesium hydroxide/ Crohn’s disease, ischemic colitis milk of magnesia (3) Drugs (1) Drug action (4) Functional—irritable bowel syndrome (a) Variety of poorly absorbed salts (5) Malabsorption—sprue, pancreatic that draw water into intestinal lu- insufficiency, lactase deficiency men causing fecal mass to soften (6) Postsurgical—postgastrectomy dump- and swell; swelling stretches ing syndrome intestinal lumen and stimulates (7) Systemic diseases—diabetes, peristalsis hyperthyroidism (b) Treatment of acute constipation 2. Incidence—estimated that the average adult in (2) Side-effects the United States experiences 1–2 acute diar- (a) Diarrhea, abdominal cramps rheal episodes per year (b) Fluid and electrolyte disturbances 3. Risk factors (3) Drug interactions a. Travel (a) Decreased absorption of quino- b. Close contact with infected persons, e.g., lones and tetracyclines daycare, institutionalization (b) Premature absorption of enter- c. Decreased immunity—renders individuals ically coated drugs more susceptible to organisms that gener- (4) Contraindications/precautions ally do not cause symptoms in immuno- (a) Renal failure competent hosts (b) Acute surgical abdomen, intestinal obstruction, fecal impaction • Signs and symptoms (c) Pregnancy category B; no prob- 1. Abrupt onset lems reported in nursing mothers 2. Increased frequency and volume of stools 3. Patient education 3. Crampy abdominal pain a. Emphasize importance of prompt re- 4. May be associated with nausea and vomiting sponse to defecation signal 5. Dehydration if severe b. Judicious use of laxatives c. Adequate fluid intake (6–8 glasses of • Physical findings water) 1. Acute d. Increased fiber in diet a. Occasionally—low-grade fever; postural changes in pulse, blood pressure • Referral—any suspected obstructive or serious sys- b. Abdominal examination—hyperactive temic pathology bowel sounds; diffuse tenderness to palpation Diarrhea 2. Chronic—signs associated with specific causes, e.g., thyromegaly, lymphadenopathy, • Definition—defecation characterized by increased cachexia, rectal mass, impaction frequency, fluidity, or volume 1. Acute—less than 1–2 weeks duration • Differential diagnosis—diarrhea is a symptom (see 2. Chronic—more than 3 weeks duration Etiology)

• Etiology/Incidence/Risk factors • Diagnostic tests/findings 1. Etiology 1. Usually none indicated for symptoms last- a. Acute ing less than 72 hours unless associated with (1) Viral—Norwalk bloody diarrhea or patient appears ill (2) Bacterial—Salmonella, Shigella, E. coli (traveler’s diarrhea) 272 Chapter 8 Nongynecological Disorders/Problems

2. If persistent or chronic b. Antisecretory agents/bismuth a. Stool evaluation subsalicylate (1) For fecal leukocytes (1) Drug action—may involve adsorption (2) For occult blood of bacterial toxins and/or local anti- (3) For culture for bacterial pathogens inflammatory effect (4) For ova and parasites 3 3 (2) Side-effects—darkened tongue or (5) Giardia antigen assay stool (6) Clostridium difficile toxin assay (3) Drug interactions—potentiates oral (7) Qualitative fat (sudan stain)—fat anticoagulants; salicylism with aspirin content increased in presence of (4) Contraindications/precautions—hy- small bowel disease or pancreatic persensitivity to salicylates; influenza insufficiency or varicella; pregnancy category C/D b. HIV testing (third trimester); not recommended in c. Hematologic evaluation for indications of nursing mothers underlying disease c. Antibiotics (1) CBC, electrolytes, and sedimenta- (1) Indicated only when pathogen tion rate for indications of infection, identifiable dehydration (2) May exacerbate simple episode (2) TSH low in hyperthyroidism (3) Traveler’s diarrhea—ciprofloxacin or (3) Hyperglycemia in diabetes mellitus trimethoprim-sulfamethoxazole for 3 days • Management/Treatment 3. Patient education 1. Nonpharmacologic a. Maintain fluid intake a. Observation—acute attacks usually self- b. Normal diet when tolerated limited c. Use of antidiarrheal agents b. Hydration/electrolyte replacement c. Normal diet as soon as patient able to • Indications for referral tolerate 1. Blood in stools d. For lactase deficiency, limit milk products 2. Diarrhea accompanied by severe abdominal and consider exogenous lactase pain 2. Pharmacologic 3. Irreversible or progressive symptoms a. Antimotility agents—use is controversial; 4. Definitive diagnosis and management of un- avoid use in patients with bloody diarrhea derlying disease and severe systemic illness (1) Agents Hemorrhoids (a) Loperamide (b) Diphenoxalate-atropine • Definition (2) Drug action—slows intestinal transit, 1. Varicosities of the hemorrhoidal plexus in the allowing more time for absorption lower rectum or anus (3) Side-effects 2. Internal (a) Abdominal pain a. Originate above the anorectal line (b) Distention b. Covered by nonsensitive rectal mucosa (c) Dizziness, fatigue 3. External (d) Rash a. Originate below the anorectal line (e) Anticholinergic effects b. Covered by well-innervated epithelium (4) Drug interactions—diphenoxylate/ atropine • Etiology/Incidence/Risk factors (a) Potentiates MAOIs 1. Etiology (b) CNS depressant effects with alco- a. Thin-walled, dilated vessels; engorge with hol use increased intra-abdominal pressure (5) Contraindications/precautions b. Prolapse may be secondary to passage of a (a) Acute dysentery large, hard stool; increase in venous pres- (b) Pseudomembranous, ulcerative sure from pregnancy or heart failure; or colitis straining due to lifting or defecation (c) Pregnancy category B/C; not rec- 2. One of the most commonly encountered ano- ommended while nursing rectal conditions in general practice Gastrointestinal Disorders 273

3. Risk factors (b) Dermal atrophy with topical a. Constipation, straining at stool steroid; possibility of systemic b. Pregnancy absorption c. Low-fiber diet (3) Drug interactions—none d. Pelvic congestion (4) Contraindication/precautions—some e. Poor pelvic musculature are pregnancy category C; not recom- f. Loss of muscle tone with advanced age mended while nursing b. Bulk-forming agents (see Constipation • Signs and symptoms this chapter) 1. Internal—painless, bright red bleeding with c. Stool softeners (see Constipation this defecation chapter) 2. External—itching, pain, and bleeding with 3. Patient education defecation a. Regulation of bowel habits b. Dietary changes to maintain hydration, • Physical findings bulk 1. Internal c. Appropriate use of bulk laxatives, stool a. Usually not palpable unless thrombosed softeners, hemorroidal preparations b. Usually not visible unless prolapsed 2. External • Referral a. Protrude with straining or standing 1. Acute thrombosis of an external hemorrhoid b. Blue, shiny masses at the anus if 2. Failure to respond to conservative thrombosed management c. Painless, flaccid skin tags (resolved throm- botic hemorrhoids) Irritable Bowel Syndrome (IBS)

• Differential diagnosis • Definition 1. Condyloma accuminata 1. A functional disorder characterized by altered 2. Rectal prolapse bowel habits and abdominal pain 3. Rule out other causes for bleeding 2. Rome criteria helpful in establishing diagno- a. Colorectal cancer sis (Thompson, Longstretch, and Drossman, b. Polyps 1999) c. Anal fissures a. Presence for at least 12 weeks in the d. Inflammatory bowel disease preceding 12 months of continuous or e. Colonic diverticulitis recurrent abdominal pain that cannot be explained by structural/biochemical • Diagnostic tests/findings abnormalities 1. Anoscopic examination—with internal hemor- b. Associated with at least two of the rhoids bright red to purplish bulges following: 2. Additional testing if underlying pathology (1) Abdominal pain relieved with suspected defecation (2) Onset associated with change in stool • Management/Treatment—no treatment necessary frequency—diarrhea or constipation if asymptomatic (3) Onset associated with change in form 1. Nonpharmacologic of stool a. Increase bulk/fiber/fluids in diet b. Sitz baths • Etiology/Incidence/Risk factors c. Witch hazel pads or gel—may pro- 1. Etiology—proposed vide transient relief and help reduce a. Altered bowel motility inflammation b. Visceral hypersensitivity 2. Pharmacologic c. Imbalance of neurotransmitters a. Topical anesthetic/steroid suppositories d. Infection and ointments 2. Prevalence—as high as 15% in general popula- (1) Drug action—anesthetic and anti- tion; only 25% of persons with symptoms con- inflammatory action sistent with IBS seek care (2) Side-effects 3. Risk factors—female to male ratio of 2:1; late (a) Local irritation, contact dermati- teens early adulthood tis, folliculitis 274 Chapter 8 Nongynecological Disorders/Problems

• Signs and symptoms (a) Drug action—selectively inhibits 1. Refer to Rome criteria gastrointestinal smooth muscle 2. May also report bloating, fecal urgency, in- and may reduce pain and bloating complete evacuation (b) Side-effects—drowsiness, anti- 3. Presence of the following symptoms suggest cholinergic effects organic disease (alarm symptoms) (c) Drug interactions—alcohol, (a) New onset over 50 CNS depressants, additive an- (b) Pain/diarrhea that interferes with ticholinergic effects with other sleep anticholinergics (c) Fever (d) Contraindications/precautions (d) Rectal bleeding, anemia i. Glaucoma (e) Weight loss ii. Unstable cardiovascular (f) Persistent diarrhea or severe disease constipation iii. GI or urinary tract obstruction • Physical findings—left-lower quadrant tenderness iv. Pregnancy category B/C; on abdominal examination contraindicated in nursing mothers • Differential diagnosis (2) Tricyclic antidepressants—amitryp- 1. Lactose intolerance tyline, nortriptyline, desipramine 2. Colon cancer (a) Drug action—analgesic and 3. Infectious disease/parasitic infestation mood-enhancing properties; anti- (Giardia) cholinergic effects 4. Inflammatory disease (ulcerative colitis, (b) Side-effects—drowsiness, anti- Crohn’s disease) cholinergic effects 5. Laxative abuse (c) Drug interactions—fluoxetine, MAO inhibitors, alcohol, CNS • Diagnostic tests/findings depressants 1. Limited work-up in patients lacking alarm (d) Contraindications/precautions symptoms i. During or within 14 days of a. CBC, chemistry panel, sedimentation rate MAO inhibitors; postacute MI b. Stool studies including fecal leukocytes, ii. Pregnancy category C; not occult blood, ova, and parasites recommended in nursing c. Flexisigmoidoscopy mothers d. If patient is 50 years old or older, b. Diarrhea predominant colonoscopy or barium enema and (1) Loperamide, diphenoxylate/atropine flexisigmoidoscopy (see Diarrhea this chapter) (2) Alosetron • Management/Treatment (a) Drug action—a 5-HT3 receptor 1. Nonpharmacologic antagonist, decreases intestinal a. Effective patient–provider relationship; secretion, motility, and afferent reassurance of benign nature of disease pain signals b. Diet (b) Limited use for women with (1) Decrease caffeine, alcohol, fatty foods, severe chronic diarrhea pre- gas forming foods, or products con- dominant IBS; unresponsive to taining sorbitol; limit milk products if conventional therapy and not lactose intolerance suspected caused by anatomic or metabolic (2) Increase fiber in diet or in the form of abnormality supplements (c) Side-effects—possible severe c. Stress management, relaxation tech- adverse GI effects including niques, identify “triggers” ischemic colitis and serious com- d. Exercise plications of constipation result- 2. Pharmacologic—use patient’s symptoms as a ing in hospitalization, and rarely guide blood transfusion, surgery, and a. Pain predominant death (1) Antispasmodic/anticholinergic— (d) Contraindications/precautions— dicyclomine hydrochloride, only healthcare providers en- L-hyoscyamine sulfate rolled in Lotronex (alosetron) Gastrointestinal Disorders 275

prescribing program should pre- • Signs and symptoms—classic sequence of scribe; discontinue immediately symptoms in patients who develop consti- 1. Pain is initial symptom; begins in epigastrum pation or symptoms of ischemic or periumbilical area colitis 2. Anorexia, nausea, or vomiting c. Constipation predominant 3. Pain localizes to RLQ after several hours (1) Fiber supplements—psyllium, poly- 4. Sense of constipation; infrequently diarrhea carbophil, methylcellulose (see Con- stipation this chapter) • Physical findings (2) Osmotic laxative—lactulose, sorbi- 1. Fever of â99–100°F (> 100° F may indicate tol, polyethylene glycol, magnesium peritonitis) hydroxide (see Constipation this 2. Tenderness localized to McBurney’s point; chapter) pain worsened and localized with cough (3) Lubiprostone 3. Signs of peritoneal irritation—guarding, rigid- (a) Drug action—chloride channel ity, and rebound tenderness RLQ activator, enhances GI motility 4. Absent bowel sounds (b) Indicated only for adult women 5. Positive psoas sign—pain with flexion at the with constipation-predominant hip against resistance or hyperextension IBS 6. Positive Rovsing’s sign—RLQ pain elicited (c) Side-effects—nausea, headache, when LLQ is deeply palpated and pressure is diarrhea, abdominal pain released (d) Contraindications/precautions— 7. Positive obturator sign—pain with passive in- younger than 18 years of age; ternal rotation of flexed right hip/knee renal or hepatic impairment; 8. Rectal examination may reveal tenderness/ pregnancy category C; not recom- mass mended in nursing mothers; discontinue if diarrhea occurs • Differential diagnosis 3. Patient education 1. Ovarian, e.g., mittelschmerz, cyst a. Appropriate implementation of the non- 2. Ectopic pregnancy pharmacologic measures 3. Pelvic inflammatory disease b. Reassurance of the relative benign nature 4. Pyelonephritis, calculi of disorder 5. Gallbladder or pancreatic inflammation c. Need for reevaluation if symptoms pro- 6. Gastroenteritis gress or change • Diagnostic tests/findings • Referral—onset in those older than 50; presence 1. White blood cell count—moderate leukocyto- of symptoms suggestive of organic disease/alarm sis 10,000–18,000/mm3 symptoms 2. Urinalysis may demonstrate hematuria and pyuria Appendicitis 3. Pregnancy test 4. Ultrasound diagnostic in 85% of patients • Definition—inflammation of the wall of the vermi- 5. Focused appendix computerized tomogra- form appendix that may result in perforation with phy (FACT)—highly specific and sensitive but subsequent peritonitis time and expense limits usefulness in routine diagnosis • Etiology/Incidence 1. Etiology • Management/Treatment a. Based on operative findings, classified as 1. Nonpharmacologic—none simple, gangrenous, or perforated 2. Pharmacologic—none b. Acute appendicitis secondary to obstruc- 3. Patient education tion due to fecal material, lymphoid hy- a. Need for emergency care if pain or other perplasia, foreign bodies, or parasites with symptoms change during observation, secondary bacterial infection evaluation period c. Gangrene and perforation develop within b. Postoperative care instructions 24–36 hours; perforation results in release of luminal contents into peritoneal cavity • Referral—immediate surgery consult for acute 2. Incidence—occurs in all age groups; highest abdomen incidence in males 10–30 years of age 276 Chapter 8 Nongynecological Disorders/Problems

Peptic Ulcer Disease (PUD) b. Rectal bleeding or melena; anemia c. Weight loss, dysphagia • Definition—group of ulcerative disorders involv- d. Abdominal mass, jaundice ing the upper GI tract that requires acid and pep- e. Family history of gastric cancer sin and/or abnormal mucosal resistance for their f. Anorexia/early satiety formation • Physical findings • Etiology/Incidence/Risk factors 1. Usually none in uncomplicated peptic ulcer 1. Etiology disease a. Acid and pepsin activity overpower mu- 2. Occasionally, well localized epigastric cosal defenses to produce ulcers when tenderness mucosal defense is impaired by exogenous factors/Helicobactor pylori and NSAIDs • Differential diagnosis b. H. pylori is an established causative factor; 1. Gastroesophageal reflux disease 90–95% of duodenal ulcer patients and 2. Nonulcer dyspepsia 70–80% of gastric ulcer patients infected 3. Gastric carcinoma with H. pylori 4. Angina c. H. pylori is a gram-negative bacterium; produces urease that breaks down urea- • Diagnostic tests/findings

forming ammonia and CO2 allowing or- 1. Stool for occult blood ganism to control pH of its environment 2. H. pylori testing d. NSAIDs damage mucosa through a di- a. Noninvasive—unless indications for en- rect action and systemically by inhibiting doscopy, use serology to identify infection endogenous prostaglandin synthesis; and stool antigen test or urea breath test NSAID-related ulcers more likely to be to determine cure, if indicated gastric (1) Serologic test—ELISA detects IgG 2. Incidence antibodies indicating current or past a. Estimated 5–10% of the general infection; may or may not revert to population negative after treatment b. Male/female ratio nearly equal (2) Stool antigen test—reverts to negative c. Duodenal ulcers more common; peak in- within 5 days/few months after eradi- cidence of gastric ulcers ages 55–65 cation of organism 3. Risk factors (3) Urea breath test—detects presence or a. Family history—likely due to familial absence of active infection transmission of H. pylori b. Invasive testing—mucosal biopsy during b. Cigarette smoking—delays healing and endoscopy increases risk of recurrence (1) Histologic testing c. Steroids (2) Rapid urease testing (3) Culture • Signs and symptoms 1. Burning or deep epigastric pain that occurs • Management/Treatment 1–3 hours after meals; relieved by ingestion of 1. Nonpharmacologic food or antacids a. Avoid aspirin and NSAIDs 2. Pain commonly causes early morning b. Smoking cessation if appropriate awakening c. Decreased intake of coffee and other 3. Other dyspeptic symptoms—nausea, vomit- caffeine-containing beverages ing, belching, bloating d. Attend to stress-related issues 4. Symptomatic periods occur in clusters lasting 2. Pharmacologic a few weeks followed by symptom-free periods a. Disease not due to H. pylori for weeks/months (1) Histamine (H2RA) receptor antago- 5. Gastric ulcer presentation more variable; food nists—cimetidine, ranitidine, nizati- may make symptoms worse dine, famotidine 6. Complications—hemorrhage, perforation, (a) Drug action—inhibits acid secre- obstruction tion by blocking H2 receptors in 7. Alarm symptoms for gastric cancer or compli- parietal cell cated PUD (b) Side-effects a. Older than 45 years i. Headache, fatigue, dizziness Gastrointestinal Disorders 277

ii. Minimal GI upset 3. Obtain surgical consultation for patients with (c) Drug interactions—may alter ab- evidence of bleeding, gastric outlet obstruc- sorption of certain drugs second- tion, or perforation ary to changes in gastric pH (d) Contraindications/precautions Viral Hepatitis i. Severe renal insufficiency ii. Pregnancy category B; not • Definition—a group of systemic infections involv- recommended while nursing ing the liver with common clinical manifestations (2) Proton pump inhibitors (PPIs)— caused by different viruses with distinctive epide- omeprazole, lansoprazole, rabepra- miologic patterns zole, pantoprazole, esomeprazole (a) Drug action—inhibits gastric • Etiology/Incidence/Risk factors acid secretion by inhibiting the 1. Hepatitis A virus (HAV) final step in acid secretion by al- a. Spread via fecal–oral route; spreads readily tering the activity of the proton in households and child care centers pump; virtual cessation of acid b. Mean incubation time 25 days; range 15 production to 60 days; maximum infectivity 2 weeks (b) Side-effects before jaundice; acute onset i. Headache c. Infections in infancy/childhood generally ii. Nausea, abdominal pain, flat- mild without jaundice; adult infections ulence, constipation, diarrhea can be severe (c) Drug interactions—may interact d. Self-limited; no carrier state or chronic with drugs that depend on gastric liver disease results pH for absorption e. Accounts for more cases of acute viral (d) Contraindications/precautions hepatitis than all other hepatotropic vi- i. Omeprazole—pregnancy cat- ruses combined egory C; not recommended 2. Hepatitis B virus (HBV) while nursing a. Transmitted in blood, blood products, and ii. Lansoprazole—pregnancy infected body fluids (saliva, vaginal secre- category B; caution while tions, semen) by parenteral, sexual, peri- nursing natal exposure b. Ulcers caused by H. pylori—eradication of b. Mean incubation time 75 days; range 28 to H. pylori to reduce risk of recurrent duode- 160 days nal ulcer c. Spectrum of illness ranging from asymp- (1) PPI triple therapy—lansoprazole, tomatic seroconversion to acute illness; amoxicillin, clarithromycin fulminant hepatitis results in less than 1% (2) Bismuth quadruple therapy—bis- d. Up to 10% infected as adults and 90% muth, metronidazole, tetracycline, infected as neonates become chronic car-

plus PPI or H2RA riers; increased risk of cirrhosis, hepato- (3) Persistent H. pylori infection—retreat cellular carcinoma with alternative combination 3. Hepatitis C virus (HCV) 3. Patient education a. Associated with IV drug use and blood a. Importance of positive life style changes, transfusion before 1992; other risks in- e.g., smoking cessation, decreased alcohol clude drug inhalation, multiple sex part- consumption ners, body piercing/tattooing, needle stick b. Purpose, dosage, side-effects of injuries, hemodialysis; sexual transmis- medications sion accounts for less than 5% of cases; c. Importance of compliance with medica- perinatal transmission occurs in 3–5% of tion regimen infants born to infected mothers b. Mean incubation time 50 days; range 2 to • Referral 22 weeks; onset insidious 1. Patients with weight loss, dysphagia, anorexia, c. Acute disease often mild in adults; asymp- vomiting, hematemesis/melena; new onset tomatic in children pain in patient over 45 d. Up to 80% of patients develop chronic 2. If treatment for H. pylori fails second time, re- hepatitis; 20–30% eventually develop cir- ferral indicated rhosis or hepatocellular carcinoma 278 Chapter 8 Nongynecological Disorders/Problems

4. Hepatitis D virus (HDV) 3. Jaundice a. A defective virus that requires co-infection 4. Hepatomegaly with HBV; may be transmitted with HBV 5. Splenomegaly or as superinfection in established chronic HBV infection • Differential diagnosis—noninfectious causes of b. Transmitted through blood/blood prod- hepatitis, e.g., hepatotoxic drugs, alcohol ucts, IV drug use, or sexual contact c. Incubation period for superinfection is • Diagnostic tests/findings 2–8 weeks 1. Viral serologies (see Table 8-4) d. Contributes to severity of HBV infection 2. Urinalysis—positive for protein, bilirubin e. Suspect superinfection with HDV in pa- 3. Liver function tests tient who presents with fulminant hepati- a. Marked elevation—alanine aminotrans- tis and chronic HBV ferase (ALT) and aspartate aminotrans- 5. Hepatitis E virus (HEV) ferase (AST) a. Spread via fecal–oral route b. Mild elevation of alkaline phosphatase b. Endemic in developing countries c. Normal serum bilirubin or mild c. Mean incubation time 27 days; range 2 to bilirubinemia 9 weeks d. More common in children and young • Management/Treatment adults; infection during pregnancy can 1. Nonpharmacologic lead to liver failure a. Activity as tolerated; avoid strenuous ac- e. No risk of chronicity or carcinoma tivities or contact sports 6. Miscellaneous viral causes b. Hydration a. Herpes simplex virus c. Maintain adequate caloric intake and bal- b. Epstein-Barr virus anced diet; small feedings may be better c. Cytomegalovirus tolerated d. Discontinue all but essential medications • Signs and symptoms—all viral types produce very e. Avoid alcohol similar syndromes; severity of illness can vary 2. Pharmacologic widely a. Antiemetics if indicated for nausea— 1. Phase 1—incubation trimethobenzamide (Tigan) a. Asymptomatic (1) Drug action—acts centrally to inhibit b. Weeks to months the medullary chemoreceptor trigger 2. Phase 2—pre-icteric (prodromal) zone a. 3 to 10 days in length (2) Side-effects—drowsiness, dizziness, b. Malaise, fatigue blurred vision, hypotension c. Anorexia, nausea, vomiting (3) Drug interactions—potentiates alco- d. “Flu-like” aches, headache hol, other CNS depressants e. Skin rash (4) Contraindications/precautions— f. Change in sense of smell or taste; aversion pregnancy category C; not recom- to cigarettes mended while nursing 3. Phase 3—icteric b. Chronic hepatitis B a. 1 to 4 weeks in length (1) Antiviral treatment indicated for b. RUQ pain active viral replication (sustained c. Dark-colored urine presence of HBeAg and HBV DNA), d. Clay-colored stools elevated ALT levels, and histologic evi- e. Jaundice of skin, sclera, nail beds dence of chronic liver injury 4. Phase 4—convalescence (2) Agents approved for treatment of a. May last weeks to months chronic HBV—interferon alfa, lami- b. Chronic disease develops in certain types vudine, entecavir, adefovir dipivoxil, c. Hepatitis B, C, D may be fatal; HEV 30% telbivudine mortality rate in pregnant women c. Chronic hepatits C—peginterferon in combination with ribavirin • Physical findings d. Prevention 1. Rash—maculopapular and urticarial lesions (1) HAV 2. Low-grade fever (a) Immune globulin (b) HAV vaccine Gastrointestinal Disorders 279 HEV N.A. N.A. N.A. N.A. N.A. N.A. N.A. N.A. N.A. HDV N.A. N.A. Positive Negative + co-infection HBV + superinfection + active viral replication+ active viral replication N.A. N.A. N.A. N.A. Positive HCV N.A. N.A. N.A. N.A. + late in acute & chronic infection + confirms N.A. HBV N.A. N.A. + acute & chronic infection+ resolution N.A. + acute stage, resolves 3-12 mos Remote/resolved inf.+ active viral replication+ active viral replicationN.A. N.A. N.A. N.A. N.A. N.A. HAV + acute stage & up to 12 months Remote infection/ immunity N.A. N.A. N.A. N.A. N.A. N.A. N.A. N.A. Serologic Diagnosis and Markers of Active or Chronic Hepatitis Test Name Test Table 8-4 â Table Â IgM anti-HAV IgG anti-HAV HbsAg Anti-HBs IgM anti-HBc IgG anti-HBc HBeAg HBV DNA Anti-HCV HCV RNA Anti-HDV KEY: IgM anti-HAV = immune globulin M class, HAV antibody = immune globulin M class, HAV IgM anti-HAV KEY: antibody = immune globulin G class, HAV IgG anti-HAV HBsAg = hepatitis B surface antigen Anti-HBs = HBV surface antibody IgM anti-HBc = immune globulin M class, HBV core antibody IgG anti-HBc = immune globulin G class, HBV core antibody HBeAg = HBV e antigen Anti-HCV = hepatitis C antibody Anti-HDV = hepatitis D antibody HEV = no commercially available serologic test HBV DNA = hepatitis B deoxyribonucleic acid HCV RNA = hepatitis C ribonucleic acid N.A. = Not Applicable 280 Chapter 8 Nongynecological Disorders/Problems

(2) HBV 2. Incidence—gallstones occur in 10–15% of the (a) HBIG US population (b) HBV vaccine a. Majority of patients with gallstones have 3. Patient education asymptomatic disease a. Careful disposal of infected wastes b. About 20% of asymptomatic patients de- b. Scrupulous hand-washing, food-handling velop symptoms over a period of 20 years; techniques majority present with biliary pain rather c. Need for prophylactic immunization of than biliary complication contacts, household members 3. Risk factors for cholethiasis d. Safer sexual practices a. Female gender e. Avoidance of blood contamination—no b. Advanced age sharing toothbrushes, razors, needles c. Obesity f. Laboratory follow-up d. Multiparity, pregnancy (1) Monitor aminotransferase at 1–4 week e. Rapid weight loss intervals during acute illness f. Hypertriglyceridemia (2) Monitor HBsAg and anti-HBsAg until g. Medications/oral contraceptives anti-HBs present • Signs and symptoms • Referral 1. Biliary colic—presenting symptom in more 1. Fulminant disease—patients presenting with than 90% of patients altered mental state a. Severe, steady pain localized to the epi- 2. Chronic HBV patients who require treatment gastrum or RUQ; may radiate to back or 3. HCV—early identification/referral important scapula because evidence suggests that early treat- b. Pain is precipitated by spasm of a dilated ment reduces risk of chronic infection cystic duct obstructed by gallstone(s) c. Attacks of biliary colic more common at Cholecystitis night d. Pain typically has a sudden onset and • Definition may last 3 hours; may be accompanied by 1. Gallstones/cholelithiasis nausea/vomiting 2. Biliary colic is most common symptom of 2. Acute cholecystitis cholelithiasis and results from transient ob- a. Pain similar to biliary colic but lasts lon- struction of the cystic duct by a stone ger; associated with nausea/vomiting and 3. Acute cholecystitis is the most common com- fever plication of cholelithiasis and develops when b. Symptoms of local inflammation and sys- gallstone(s) obstruct the cystic duct resulting temic toxicity in distention and inflammation of the gall- c. Pain shifts from epigastrum to RUQ; se- bladder; secondary bacterial infection occurs quence secondary to visceral pain from in about 50% of cases ductal impaction by stones progressing to 4. Choledocholelithiasis is the presence of stones inflammation of the gall bladder with pari- in the common bile duct and occurs in 10–15% etal pain of patients with cholelithiasis; associated with d. Most patients have had previous attacks of high rate of complications—jaundice, acute biliary colic cholangitis, gallstone pancreatitis 3. Choledocholithiasis—stones in the common 5. Acute acalculous cholecystitis occurs in seri- bile duct ously ill hospitalized patients; probably associ- a. May remain asymptomatic ated with biliary “sludge” b. May result in biliary pain, obstructive jaundice, ascending cholangitis (bacte- • Etiology/Incidence/Risk factors rial infection of biliary tract), or biliary 1. Etiology pancreatitis a. Gallstones may be result of imbalance in 4. Acute suppurative cholangitis—pain, jaundice, bile components chills/Charcot’s triad b. About 85–95% of gallstones are composed 5. Pancreatitis—upper abdominal pain radiating primarily of cholesterol to the back c. Pigment stones are composed of calcium bilirubinate; less common Gastrointestinal Disorders 281

• Physical findings—acute cholecystitis Gastroesophageal Reflux Disease (GERD) 1. Fever 2. Murphy’s sign—inspiratory arrest secondary to • Definition pain during deep palpation of right subcostal 1. Gastroesophageal reflux refers to movement region; relatively specific finding of gastric contents from the stomach into the 3. Gallbladder distended and palpable esophagus 4. Jaundice 2. GERD refers to symptomatic clinical condition 5. Localized tenderness may be only finding in or histologic alteration that results from epi- elderly patients; pain and fever may be absent sodes of reflux 3. When esophagus is repeatedly exposed to re- • Differential diagnosis fluxed material for prolonged periods of time, 1. Appendicitis inflammation of esophagus can occur 2. Pancreatitis 4. Complications—esophagitis; strictures; Bar- 3. Ruptured ectopic pregnancy or ovarian cyst rett’s esophagus, which carries a 10% risk of 4. Peptic ulcer disease progression to adenocarcinoma

• Diagnostic tests/findings • Etiology/Incidence/Risk factors 1. Ultrasound 1. Etiology a. Has a 95% sensitivity for detecting stones a. Contributing factors include reflux of in the gallbladder; detects bile duct stones caustic gastric contents, a breakdown in in only 50% of cases defense mechanism of esophagus, and b. Best noninvasive imaging technique to a functional abnormality that results in diagnose acute cholecystitis; findings reflux include thick gallbladder wall, gallblad- b. Most common etiology is prolonged der distension, sludge in the lumen, peri- esophageal acid exposure due to transient cholecystic fluid lower esophageal relaxations 2. Heptatobiliary scintigraphy—can confirm/ c. Less common mechanisms include patho- exclude diagnosis of acute cholecystitis with logically weak lower esophageal sphincter high degree of sensitivity/specificity (LES) tone, hiatal hernia, esophageal mo- 3. Endoscopic retrograde cholangiopancreatog- tility disorder, Zollinger-Ellison syndrome, raphy (ERCP)—best study for diagnosis of and delayed gastric emptying choledocholithiasis 2. Incidence 4. Computerized tomography (CT)/MRI— a. Physiologic reflux occurs in normal comparable to ERCP in terms of diagnostic individuals accuracy b. Reflux occurs regularly in up to 40% of 5. Leukocytosis with a “left shift” observed in healthy individuals who do not seek acute cholecystitis; serum aminotranferases, treatment alkaline phosphatase, bilirubin, and amylase 3. Risk factors may also be elevated a. Foods that lower LES pressure—high fat, 6. Elevation of serum bilirubin and alkaline chocolate, peppermints phosphatase in choledocholithiasis b. Foods that irritate esophageal mucosa— 7. Amylase greater than 1000 U/dL indicates citrus fruits, spicy tomato drinks acute pancreatitis c. Drugs that lower LES pressure—calcium channel blockers, progesterone • Management/Treatment d. Cigarette smoking, alcohol 1. Expectant management for patients with e. Pregnancy asymptomatic gallstones f. Obesity 2. Elective cholecystectomy for most patients with symptomatic cholelithiasis • Signs and symptoms 3. Acute cholecystitis managed with hospital ad- 1. “Heartburn”—retrosternal burning sensation mission; early cholecystectomy once patient is radiating upward stable 2. Acid regurgitation—effortless return of gastric 4. Bile duct stones should be removed whether contents into pharynx symptomatic or not because of high rate of 3. Symptoms usually occur postprandially complications 4. Symptoms aggravated by reclining, straining, bending, or stooping 282 Chapter 8 Nongynecological Disorders/Problems

5. Atypical symptoms d. Avoid recumbency for 3 hours a. Odynophagia—burning, squeezing pain postprandially with swallowing e. Reduce fat to no more than 30% of calories b. Dysphagia—sensation of food lodged in f. Reduce consumption of alcohol, choco- the chest secondary to stricture late, colas, coffee, peppermint, citrus c. Globus sensation—sensation of lump in juices, tomato products the throat 2. Pharmacologic 6. Extraesophageal symptoms a. Commercially available antacids and anti- a. Hoarseness refluxants/alginic acid are useful for mild b. Chronic cough symptoms c. Asthma/reactive airway disease (1) Drug action d. Hiccups (a) Neutralizes acids e. Dental disease (b) Produces foaming neutral barrier f. Nausea to reflux (2) Side-effects—diarrhea, constipation • Physical findings (3) Drug interactions—reduces absorp- 1. Usually normal examination tion of tetracycline, possibly other 2. Occasionally epigastric tenderness with drugs palpation (4) Contraindications/precautions— impaired renal function

• Differential diagnosis b. H2-receptor antagonists (acid reducers)— 1. Cardiac chest pain effective treatment for less severe GERD 2. Peptic ulcer disease (see PUD this chapter) 3. Infectious esophagitis—viral, fungal c. Proton pump inhibitors (acid suppressant 4. Medication-induced esophagitis—antibiotics agents)—most effective agents for healing 5. Esophageal/gastric malignancy esophagitis and preventing complications 6. Hepatobiliary disease (see PUD this chapter) 3. Patient education—life style modifications • Diagnostic tests/findings 1. Diagnosis of GERD based on clinical findings • Referral and confirmed by response to therapy 1. Symptoms of dysphagia, weight loss, blood 2. Diagnostic evaluation if symptoms chronic or loss, obstructive symptoms including nausea/ refractory to therapy or if esophageal compli- vomiting, early satiety, anorexia cations suspected 2. Long-standing or refractory cases a. Endoscopy 3. Candidates for surgical intervention (1) Useful for diagnosis of complications—esophagitis, strictures, Barrett’s Â Hematologic Disorders esophagus (2) Indications Anemias (a) Dysphagia or odynophagia (b) Weight loss • Definition (c) Evidence of GI bleeding or iron 1. Abnormally low hemoglobin concentration deficiency anemia (< 12 g/dL for women 13 g/dL for men) or in- (d) Screen for Barrett’s if 10 years or adequate red blood cell population (RBC) more of GERD symptoms 2. Numerous diverse causes b. Upper GI may demonstrate structural 3. Usually classified according to RBC size— problems; evaluation of dysphagia mean corpuscular volume/MCV c. Ambulatory esophageal pH monitoring— a. Microcytic anemia (MCV < 80 fL), e.g., iron best test to establish abnormal acid reflux deficiency anemia, thalassemia trait b. Macrocytic anemia (MCV > 100 fL), e.g.,

• Management/Treatment B12 deficiency, folate deficiency, liver 1. Nonpharmacologic disease a. Weight loss c. Normocytic anemia (MCV 80–100 fL), e.g., b. Smoking cessation anemia of chronic disease, hemolysis/ c. Elevate head of bed (HOB); sleep on hemoglobinopathy/sickle cell disease, wedge-shaped bolster renal failure Hematologic Disorders 283

• Etiology/Incidence—commonly encountered (2) Folic acid deficiency due to anemias (a) Malabsorption syndromes 1. Iron deficiency anemia (IDA) (b) Increased demand—pregnancy, a. Etiology infancy (1) Blood loss—GI overt/occult, (c) Inadequate intake—alcoholics, menorrhagia elderly (2) Inadequate dietary intake—most (3) Certain drugs decrease folic acid lev- common in infants and adolescents els—oral contraceptives, dilantin (3) Metabolic demands in excess of in- b. Incidence take—pregnancy, lactation (1) Found in all races and age groups b. Incidence (2) Most common megaloblastic anemia (1) Most common form of anemia; repre- in pregnancy sents 25% of all anemia cases c. Risk factors (2) Affects 10–15% of premenopausal (1) Pregnancy women (2) Alcoholism c. Risk factors 5. Sickle cell anemia (1) Female gender a. Etiology (2) Menorrhagia (1) A chronic hemolytic anemia charac- (3) Pregnancy terized by sickle-shaped RBC 2. Anemia of chronic disease (2) Autosomal recessive genetic disorder a. Etiology (a) Hgb S develops instead of Hgb A (1) A hypoproliferative anemia associated (b) Individual is homozygous for with underlying chronic disorders Hgb S such as infections, inflammatory dis- b. Incidence orders, and malignancy (1) Homozygous Hgb S in an estimated (2) Reduced production and response 0.5% African Americans to erythropoietin; decreased RBC life (2) Heterozygous trait in an estimated 8% span of African Americans; essentially (3) Defect in iron-reutilization asymptomatic carrier state b. Incidence—second most common anemia (3) Most common hemoglobinopathy in

3. Vitamin B12 deficiency anemia the US a. Etiology c. Risk factors

(1) B12 deficiency alters DNA synthesis (1) African-American race

(2) B12 deficiency develops secondary to (2) Lower frequency in persons of Medi- lack or relative deficiency of intrinsic terranean ancestry factor that leads to impaired vitamin

B12 absorption (pernicious anemia) • Signs and symptoms (a) Autoimmune reaction involving 1. Iron deficiency anemia gastric parietal cells a. Asymptomatic unless severe, then (b) History of gastrectomy nonspecific (3) Rarely secondary to nutritional defi- b. Fatigue, generalized weakness

ciency of vitamin B12 c. Dyspnea on exertion b. Incidence—regarded as a disorder affect- d. Headaches ing older persons of northern European e. Pica descent; likely underrecognized in other 2. Anemia of chronic disease populations a. Symptoms common to all anemias—fa- c. Risk factors tigue, weakness, exertional dyspnea, light (1) Usually presents around age 60, famil- headedness, anorexia ial tendency b. Other signs and symptoms related to spe- (2) Both sexes equally affected cific underlying disease

(3) Strict vegan diet 3. Vitamin B12 deficiency (4) Recent gastric surgery a. None at first, insidious onset 4. Folic acid deficiency anemia b. Fatigue, weakness, lightheadedness a. Etiology c. Dyspnea, palpitations (1) Folic acid deficiency alters synthesis d. GI disturbances—anorexia, bloating, of DNA and RBC maturation diarrhea 284 Chapter 8 Nongynecological Disorders/Problems

e. Sore tongue (1) Temperature, pulse, respirations f. Neurologic—paresthesias, ataxia elevated g. Loss of taste and smell (2) Hypotension 4. Folate deficiency—signs and symptoms simi- (3) Pallor, cyanosis secondary to poor

lar to vitamin B12 deficiency, except there is no oxygenation neurologic involvement (4) Scleral jaundice 5. Sickle cell (5) Decreased skin turgor a. Often none during remissions b. Chronic findings due to anemia, vaso- b. Vaso-occlusvie crises—precipitating fac- occlusive events, end-organ damage tors include infection, physical or emo- (1) Cardiomegaly tional stress, blood loss (2) Skin ulcers, especially on lower (1) Malaise, chills extremities (2) Pain, especially in bones, abdomen, (3) Osteomyelitis chest, lower legs (4) Retinopathy (3) Headaches, epistaxis, vomiting (5) Renal disease—hematuria (4) Difficulty or refusal to walk • Differential diagnosis • Physical findings 1. Iron deficiency anemia 1. Iron deficiency anemia a. Anemia of chronic disease a. Often none b. Thalassemia trait b. Skin or conjunctival pallor c. Sideroblastic anemia c. Glossitis, stomatitis 2. Anemia of chronic disease—diagnosis of d. Tachycardia with/without systolic flow exclusion murmur a. Iron deficiency anemia e. Tachypnea b. Anemia of renal disease

f. Nail changes 3. Vitamin B12 deficiency (1) Spoon shaped (koilonychia) a. Nutritional deficiency (2) Brittle, easily split b. Malabsorption g. Hair thinning, breaking c. Chronic alcoholism 2. Anemia of chronic disease d. Chronic gastritis (H. pylori infection) a. Ill appearance e. Folic acid deficiency b. Signs of precipitating illness 4. Folate deficiency

3. Vitamin B12 deficiency a. Pernicious anemia a. Skin pale, occasionally jaundiced b. Medication, toxins b. Stomatitis, glossitis, smooth beefy red 5. Sickle crises tongue a. Appendicitis c. Tachycardia, arrhythmias, systolic flow b. Acute cholecystitis murmur c. Pneumonia d. Organomegaly—hepatomegaly, splenomegaly • Diagnostic tests/findings e. Neurologic 1. World Health Organization standard for ane- (1) Ataxia, positive Romberg test mia diagnosis (2) Hyperactive reflexes a. Hemoglobin 13 g/dL or less in men (ap- (3) Peripheral loss of sensation, de- proximately 38% hematocrit) creased vibratory sense, impaired b. Hemoglobin 12 g/dL or less in women (ap- proprioception proximately 35% hematocrit) (4) Changes in mental state with possible 2. Severe anemia (symptomatic) generally less wide range of expression—mild con- than 25% Hct fusion to acute psychosis 3. Iron deficiency anemia—hypochromic micro- 4. Folate deficiency cytic RBCs a. Pallor a. RBC changes in early disease may be mild b. Tachycardia, tachypnea b. MCV less than 80 fL c. Malnourished appearance c. Increased red cell width (RDW) d. No neurologic findings d. Serum ferritin less than 10 mg/L 5. Sickle cell (1) Levels reflect iron stores; single most a. In crises useful test for diagnosing IDA Hematologic Disorders 285

(2) Ferritin is an acute-phase reactant; (b) Ongoing monitoring every 3 may be elevated in inflammatory months until stable disease b. Pharmacologic e. Decreased reticulocyte count (1) Ferrous sulfate—may need to con- 4. Anemia of chronic disease—normochromic- tinue therapy 4–6 months to replenish normocytic early in course, becomes iron stores; may discontinue when microcytic serum ferritin exceeds 50 mg/L a. Anemia is typically mild; hematocrit re- (a) Drug action—replenishes de- mains around 30% pleted iron stores; incorporated b. Low serum iron levels; normal or in- into hemoglobin; allows the creased TIBC transportation of oxygen via c. Normal or increased serum ferritin hemoglobin

5. Vitamin B12 deficiency—megaloblastic- (b) Side-effects macrocytic anemia i. Nausea, vomiting, GI upset a. MCV greater than 100 fL ii. Black stools

b. Serum B12 decreased, less than 100 pg/mL iii. Constipation c. Peripheral blood smear—RBCs of widely (c) Drug interactions varying size (anisocytosis) and shape i. Antacids, calcium supple- (poikilocytosis) ments inhibit iron absorption d. Serum methylmalonic acid and homo- ii. Inhibits tetracycline cysteine levels elevated absorption e. Schilling test or assay for anti-intrinsic fac- (d) Contraindications/precautions tor antibody i. Hemochromocytosis

(1) Obtain if vitamin B12 deficiency ii. Caution in elderly detected iii. Caution with peptic ulcer (2) Helps distinguish lack of intrinsic fac- 2. Anemia of chronic disease tor from malabsorption a. Nonpharmacologic—treatment of un- 6. Folate deficiency—megaloblastic-macrocytic derlying disorder; transfusion if severe anemia anemia

a. MCV greater than 100 fL b. Pharmacologic—none; iron, folate and B12 b. Serum folate less than 3 ng/mL; normal have not been shown to be effective

serum B12 3. Vitamin B12 deficiency c. Elevated homocysteine level; normal a. Nonpharmacologic—none methylmalonic acid level b. Pharmacologic

7. Sickle cell anemia (1) B12/cyanocobalamin—dose IM daily a. Hgb of 7–9 g/dL; hematocrit 20–30% for one week, then weekly until Hct is b. Mild leukocytosis—12,000 to 15,000/mm3 normal, then monthly for life c. Reticulocytosis 10–25% (2) Cyanocobalamin nasal gel—weekly d. Irreversibly sickled cells on peripheral dosing; alternate maintenance smear therapy e. Platelets maybe elevated (3) Drug action—required for f. Sickledex used for screening—sickle cells hematopoiesis present in patients with disease and trait (4) Side-effects g. Hemoglobin electrophoresis—Hgb S/85– (a) Manifested with parenteral use— 95% in sickle cell anemia; Hgb S/40% in local stinging, burning at injection sickle cell trait site; urticaria, itching; pulmonary edema, anaphylaxis • Management/Treatment (b) Manifested with intranasal use— 1. Iron deficiency anemia—identify the cause of headache, nausea, rhinitis iron deficiency and correct it (5) Drug interactions—ethanol decreases

a. Nonpharmacologic B12 absorption; decreased response (1) Diet with increased iron content with concomitant chloramphenicol, (2) Hemoglobin monitoring schedule neomycin (a) Check 3 weeks after initiation of (6) Contraindications/precautions— treatment; recheck in 6–8 weeks hypersensitivity to cobalt 286 Chapter 8 Nongynecological Disorders/Problems

4. Folate deficiency • Referral a. Nonpharmacologic—increased dietary 1. Evaluation of suspected GI blood loss sources of folic acid/legumes, leafy green 2. Sickle cell crisis vegetables, fruits and liver 3. Evaluation of resistant cases b. Pharmacologic—folic acid (1) Drug action—cofactor in biosynthe- Â Immunologic Disorders sis of nucleic acids needed for RBC synthesis Human Immunodeficiency Virus (HIV) (2) Side-effects Infection (a) Allergic reactions—skin rash, urticaria, itching • Definition (b) Gastrointestinal—nausea, bloat- 1. HIV infection produces a spectrum of disease ing, flatulence, foul taste in mouth progressing from a clinically latent or asymp- (c) CNS—sleep disturbances, irrita- tomatic state to a state of profound immuno- bility, confusion suppression with acquired immune deficiency (3) Drug interactions syndrome (AIDS) as a late manifestation (a) Oral contraceptives increase risk 2. Stages of HIV infection of folic acid deficiency a. Transmission/primary HIV infection (b) Corticosteroids increase folic acid b. Acute HIV infection/seroconversion requirements c. Asymptomatic infection/clinically latent (c) Sulfonamides decrease absorp- period with or without persistent general- tion of folic acid ized lymphadenopathy (PGL) 5. Sickle cell d. Early symptomatic infection; previously a. Nonpharmacologic referred to as “AIDS-related complex” (1) Treat all infections aggressively e. AIDS, specific clinical conditions present + 3 (2) Maintain hydration, oxygenation or CD4 cell count less than 200/mm b. Pharmacologic—maintained continuously f. Advanced HIV infection, characterized by + 3 on folic acid supplement CD4 cell count less than 50/mm c. Therapy during crisis (1) Hydration and adequate oxygenation • Etiology/Incidence (2) Analgesics for pain control 1. Etiology (3) Antibiotics for associated infections a. HIV virus transmitted through direct con- 6. Patient education tact with blood, blood products, other a. Iron deficiency anemia body fluids (1) Take iron with meals to alleviate GI b. Methods of transmission include—sexual distress; taking with orange juice or contact, sharing needles, blood transfu- other vitamin C source will enhance sions, babies born to HIV-infected moth- absorption ers, occupational exposure (2) Dietary counseling to improve iron 2. Incidence intake and overall nutrition a. Prevalence of HIV infection in general (3) Need for follow-up blood monitoring population unknown due to reluctance to disclose HIV status; reluctance to seek b. Vitamin B12 deficiency—need for monthly supplementation testing; long asymptomatic interval after c. Folate deficiency infection (1) Folate maintenance dosage b. 56,000 new HIV infections reported in US (2) Avoid overcooking folate-rich foods in 2006; prevalence estimated to be 1 to 2 d. Sickle cell million cases at end of 2003 (1) Consider genetic counseling c. Diagnosed AIDS rising faster among (2) Crises avoidance women than in other groups (a) Maintain good nutrition d. 27% of new HIV infections reported in (b) Avoid temperature extremes 2006 were female (c) Immunizations for pneumococ- e. Black females disproportionately af- cus and influenza fected—rate of infection is 19 times higher (3) Routine evaluation of body systems than in white females every 3 to 6 months f. Hispanic females have rate of infection five times higher than white females Immunologic Disorders 287

3. Risk factors 4. Advanced Disease/AIDS a. Unprotected or traumatic sexual activity, a. Usually occurs in 10 to 11 years e.g., multiple partners or partners with b. Severe infections other partners, anal intercourse, use of 5. Opportunistic infections nonbarrier contraception a. Caused by a spectrum of pathogens that b. Heterosexually acquired HIV infection ris- rarely cause disease in healthy people; ing rapidly, especially among women most occur when CD4+ count is less than c. Intravenous drug use, sharing needles 200 d. Infant of HIV-positive mother (vertical b. May be the reactivation of a previous transmission)—15–25% if woman does pathogen; may have atypical presentation not receive antiretroviral therapy during c. Causative agents include bacterial, fungal, pregnancy viral, and parasitic infections (1) Risk of transmission may be reduced (1) Candidiasis—mouth, vagina, penis, to less than 1% if pregnant woman esophagus, large intestine, skin receives multi-agent antiretroviral (2) Toxoplasmosis therapy and has undetectable viral (3) Malignancies load at delivery (4) Kaposi’s sarcoma (2) Risk of transmission greater with ma- (5) Lymphoma—late manifestation of ternal CD4+ counts of less than 200/ HIV mm3 (6) Invasive squamous cell carcinoma— e. Transfusion of blood or blood products, cervix, vulva, anus secondary to hu- artificial insemination, organ transplant man papillomavirus (HPV) recipient prior to 1985 (7) Pneumocystis carinii pneumonia— f. Healthcare worker or service worker ex- major AIDS defining diagnosis posed to blood or body fluids, e.g., needle (8) Tuberculosis stick injury, splash (9) Mycobacterium avium complex/ MAC—occurs in late stage HIV • Signs and symptoms infection 1. Acute HIV infection and seroconversion a. Moderate “flu-like” syndrome 2 to 4 weeks • Physical findings—related to immunocompro- after inoculation mised status b. Fever, diarrhea, headache, oral lesions on 1. Early findings palate, lethargy, muscle/joint pain, rash a. Lymphadenopathy lasting 2 to 4 weeks b. Dermatologic abnormalities—seborrheic c. Self-limited; patients who seek care often dermatitis, folliculitis misdiagnosed c. Oral lesions—aphthous ulcers, her- d. Seroconversion usually in 6–12 weeks; pes simplex labialis, thrush, oral hairy may take up to 6 months leukoplakia 2. HIV disease progression—asymptomatic 2. As disease progresses, more frequent skin dis- infection orders, oral lesions, infections a. 12 weeks to 8 or more years; period of intense battle by immune system • Differential diagnosis b. Influenced by general physical condition, 1. Lymphomas age, mitigating drug therapy 2. Pneumonia (1) Risk of progression correlates with 3. Tuberculosis length of seroconversion illness 4. Chronic fatigue syndrome (2) Earliest HIV detection improves op- 5. Mononucleosis portunity for successful antiviral therapy • Diagnostic tests/findings 3. Early symptomatic HIV infection 1. Diagnosis a. Usually occurs in 8 to 10 years; immune a. Enzyme-linked immunosorbant assay system begins to weaken (ELISA)—positive for HIV antibodies b. Constitutional symptoms (highly sensitive) (1) Fatigue, headache, arthralgia, myalgia b. Western Blot—confirms ELISA, detects (2) Weight loss, anorexia, diarrhea HIV (highly specific) (3) Fevers, night sweats, chills c. Oral fluid, urine, and home kits also c. Occurrence of opportunistic infections available d. Antigen tests—can directly detect virus 288 Chapter 8 Nongynecological Disorders/Problems

(1) Nucleic acid testing—use in patients (a) HIV can mutate rapidly from a suspected of having acute retroviral drug-sensitive form to a drug- syndrome resistant form (2) HIV blood culture (b) Treatment with a combination of (3) p24 antigen detects presence of HIV drugs to minimize development protein of resistance (4) RNA PCR assay and branched DNA (5) Treatment modification called for (bDNA) assay; measure amount of when HIV RNA levels fail to reach less HIV RNA in plasma than 500 copies/mL after 6 months of 2. Screening battery for women with established therapy HIV infection b. Antiretroviral drug classes a. Complete blood count every 3 months (1) Nucleoside reverse transcriptase in- b. Chemistry panel every 6 months hibitors (NRTIs) c. RPR or VDRL every 6–12 months (2) Nonnucleoside reverse transcriptase d. Varicella, cytomegalovirus inhibitors (NNRTIs) serology—baseline (3) Protease inhibitors (PIs) e. Hepatitis A, B, C—baseline and as (4) Nucleotide reverse transcriptase indicated inhibitors f. Toxoplasmosis—as indicated 3. Patient education g. Chest radiography—as indicated a. Natural history of HIV infection h. PPD skin testing every 6 months b. Explain modes of transmission i. Pap test—every 6 months first year after (1) Discuss lifelong ability to transmit diagnosis and annually thereafter virus j. Quantitative plasma HIV ribonucleic acid (2) Teach effective ways to reduce fluid (RNA) every 3 months exchange (1) Useful for predicting progression of (a) Breastfeeding contraindicated disease by indicating viral load (b) Encourage “safe sex” practices; (2) Monitoring response to antiviral condom use, limiting number of therapy partners k. CD4+ cell count every 3 months (c) Eliminate needle sharing (1) Indicative of immune status, predictor c. Emphasize behaviors that protect/ of disease progression enhance immune system (2) Complements viral load assay (1) Current immunizations (3) Normal is 800 to 1050 cells/mm3 (a) Hepatitis B and A (4) Patients with CD4+ of 200 cells/mm3 (b) Pneumococcal vaccine (every 5 or less are likely to have symptoms or years) an AIDS defining condition (c) Influenza (annually) (d) Tetanus vaccine • Management/Treatment (e) Live vaccines contraindicated 1. Nonpharmacologic (2) Stop tobacco, alcohol, street drug use a. Symptomatic treatment for fever, diarrhea (3) Nutritious diet, clean food prepara- b. Laboratory monitoring tion techniques c. Maintain optimum nutrition, extra (4) Reduce/manage stress calories (5) Exercise as tolerated 2. Pharmacologic (see Table 8-5) (6) Avoid infectious individuals, and high- a. Antiretroviral therapy for HIV suppression risk environments, e.g, child care set- (1) Highly active antiretroviral therapy tings, work settings such as hospitals (HAART)—combining three or four (7) Avoid or eliminate exposure to pets, drugs is the standard of care for treat- especially dogs, cats, or birds ment of HIV infection (8) Control travel exposures (2) Goal to reduce HIV RNA to minimal d. Drug regimens, interactions, and resis- levels for as long as possible (unde- tance—importance of adherence to medi- tectable level < 500 copies/mL) cation schedule, CD4+ monitoring (3) Decisions regarding need to change e. HIV and pregnancy implications—encour- therapy based on measured antiviral age antiviral medication to reduce vertical effect per HIV RNA levels transmission (4) HIV mutates rapidly f. Contraception Immunologic Disorders 289 Contraindications Monitor closely for hematologic toxicity and opportunistic infections; pregnancy category C; not recommended while nursing renal functions; Monitor liver, pregnancy category C; not recommended while nursing Renal insufficiency; pregnancy category B; not recommended for nursing mothers Impaired hepatic function; monitor blood, liver and hyperglycemia; pregnancy category B; not recommended while nursing Interactions Caution with other nephrotoxic, cytotoxic myelosuppressive drugs; antagonized by rifampin Metabolized by and can induce/ inhibit cytochrome P450 enzymes; drug interactions can occur with Pls and many other drugs Do not dose with ddl Metabolized by cytochrome P450 enzymes; drug interactions common; avoid rifampin Side-effects AZT—bone marrow suppression, GI effects Ddl—pancreatitis d4T/ddC—peripheral neuropathy 3TC—minimal toxicity Mild to moderate skin rash, nausea, dizziness, headache, impaired concentration, vivid dreams, insomnia (efavirenz) headache GI effects, hyperlipidemia GI effects; Indinavir—kidney stones Drug Antiretroviral Therapy for HIV Suppression (representative list) zidovudine (AZT, ZDV) zidovudine (AZT, didanosine (ddl) zalcitabine (ddC) stavudine (d4T) lamivudine (3TC) abacavir efavirenz, nevirapine, delavirdine Tenofovir nelfinavir indinavir, amprenavir, lopinavir/ saquinavir, ritonavir, ritonavir Table 8-5 â Table Â Nucleoside reverse transcriptase inhibitors â â â â â â Nonnucleoside reverse transcriptase inhibitors (NNRTI)— â Nucleotide reverse transcriptase inhibitor â Protease inhibitors (Pls)— â â â 290 Chapter 8 Nongynecological Disorders/Problems

(1) Barrier methods reduce transmission (9) Hematologic disorders— (a) Condoms—male or female for hemolytic anemia, leukopenia, vaginal or anal penetrative acts thrombocytopenia (b) Dental dams or plastic film for (10) Positive ANA (antineutrophil anti- oral contact body) test (c) Stress need for consistent bar- (11) Positive other immunologic test—an- rier use in addition to other tidouble stranded DNA (anti-dsDNA), contraception anti-Smith (anti-Sm), LE (lupus ery- (2) Oral contraceptives and depome- thematosus) cell preparation, false- droxyprogesterone acetate (DMPA) positive syphilis serology injections—not contraindicated; lim- 2. Incidence ited data indicate antiretroviral drugs a. 4–6 individuals/100,000/year have potential to either increase or b. Primarily affects women of childbearing decrease bioavailability of contracep- age tive hormones 3. Risk factors (3) Spermicides—controversy regarding a. African-American or Hispanic descent role in possible increase in vaginal b. First-degree relative with SLE susceptibility (4) IUC—not contraindicated if HIV posi- • Signs and symptoms tive or if has AIDS but is clinically well 1. Early symptoms—vague, nonspecific, fre- on antiretroviral therapy quently misdiagnosed 2. Fever, fatigue • Referral 3. Arthralgia, arthritis 1. All cases initially for full evaluation 4. Photosensitivity 2. Monitoring and titration of medications 5. Headache, depression 3. Evaluation of new symptomatology 6. Seizures

Systemic Lupus Erythematosus (SLE) • Physical findings 1. Malar rash—erythematous, flat or raised rash • Definition—chronic, inflammatory, multisystem over malar eminences disorder of the immune system characterized by 2. Discoid rash—erythematous raised patches periods of remission and exacerbation; course of with scaling disease unpredictable and highly variable 3. Alopecia 4. Oral ulcers • Etiology/Incidence/Risk factors 5. Pleurisy 1. Etiology 6. Pericarditis a. An autoimmune disorder—abnormal immune response creates antibodies to nor- • Differential diagnosis mal tissue 1. Contact dermatitis, eczema b. Associated with reaction to some medi- 2. Rheumatoid arthritis cations—chlorpromazine, hydralazine, 3. Infectious processes isoniazid, methyldopa 4. Chronic fatigue syndrome c. Criteria for diagnosis; 4 of 11 criteria to make diagnosis (American College of • Diagnostic tests/findings Rheumatology) 1. Positive ANA (1) Malar rash 2. Anti-dsDNA, anti-Sm, LE cell prep, false- (2) Discoid rash positive VDRL (3) Photosensitivity 3. CBC—anemia, leukopenia, lymphopenia, (4) Oral ulcers thombocytopenia (5) Arthritis involving two or more pe- 4. Serum creatinine to assess kidney function ripheral joints 5. Urinalysis to determine presence of hematu- (6) Serositis—pleuritis, pericarditis, or ria, cellular casts, and proteinuria peritonitis (7) Renal disorder involving proteinuria • Management/Treatment or cellular casts 1. Nonpharmacologic (8) Neurologic disorder involving seizures a. Physical rest or psychoses b. Protection from direct sunlight Immunologic Disorders 291

c. Proper diet and nutrition (b) Exacerbation of symptoms 2. Pharmacologic likely—usually mild to moderate a. Some drugs may induce or aggravate in severity symptoms (c) Pregnancy outcomes best when b. Treatment is generally symptomatic and mother has been in remission variable for at least 6 months prior to c. Nonsteroidal anti-inflammatory drugs pregnancy and has normal renal (NSAID)—may control associated fever, function arthralgias but not fatigue, malaise, major f. Avoidance of surgery, dental procedures organ system involvement when SLE symptoms present d. Corticosteroids indicated for life- g. Immunizations threatening manifestations (1) Live vaccines not advisable e. Hydroxychloroquine (2) Killed vaccines generally do not exac- (1) Drug action—antimalarial drug; may erbate SLE help treat lupus rashes and joint symptoms • Referral (2) Side-effects 1. Evaluation of new symptoms, exacerbations (a) Irreversible retinopathy, corneal 2. When invasive procedures are indicated edema 3. Social services, family or individual counseling (b) Neuromuscular dysfunction regarding chronic disease coping strategies (c) Pruritus, rash, skin pigmentation (d) Blood dyscrasias Rheumatoid Arthritis (3) Drug interactions (a) Hepatotoxic drugs • Definition—an autoimmune disorder charac- (b) Dermatotoxic drugs terized by symmetric, erosive destruction of (4) Contraindications/precautions synovial tissues resulting in deformity and loss (a) Hepatic dysfunction, alcoholism of joint function; may involve extra-articular (b) Psoriasis manifestations (c) Pregnancy category C; not recommended while nursing • Etiology/Incidence 3. Patient education 1. Etiology a. Sunscreen, protective clothing to avoid UV a. Exact etiology unknown light b. Complex of factors likely b. Relaxation, stress reduction (1) Genetic c. Individualized exercise/rest program (2) Environmental—viral, bacterial trig- d. Prompt treatment of infections ger suspected e. Avoidance of pregnancy (3) Hormonal—controversial (1) Effective contraception c. Criteria for diagnosis; 4 of 7 criteria, with (a) Controversy regarding oral con- criteria 1–4 present for at least 6 weeks traceptive (OC) effect on SLE, but (American College of Rheumatology) considered safe relative to preg- (1) Morning stiffness for more than nancy with SLE 1 hour i. Trial on OC warranted (2) Involvement of at least three joint ii. May increase symptoms groups with soft tissue swelling (b) Progestin-only methods may be (3) Swelling involving at least one of the used following joint groups—proximal (c) Intrauterine contraception interphalangeal (PIP), metacarpopha- (IUC)—may use if not severely langeal (MCP), or wrists immunocompromised (4) Symmetrical joint swelling (2) Careful supervision of obstetric care (5) Subcutaneous nodules (a) Increased risk for premature (6) Positive rheumatoid factor delivery, spontaneous abortion, (7) Radiographic changes consistent with intrauterine fetal death, intra- rheumatoid arthritis (RA) uterine growth restriction, and 2. Incidence preeclampsia a. Prevalence—approximately 1% of the population 292 Chapter 8 Nongynecological Disorders/Problems

b. Occurs twice as often in women; third to (c) COX-2 inhibitors—celecoxib, ro- sixth decades fecoxib, valdecoxib c. Increased incidence among family groups (2) Drug action—analgesic and anti- inflammatory effects • Signs and symptoms (3) Side-effects 1. Morning stiffness in joints lasting more than 1 (a) GI effects—dyspepsia, gastric and hour duodenal ulceration, perforation 2. Joint pain, constant or recurring; insidious de- and bleeding; selective COX-2 velopment over weeks to months inhibitors have less upper GI 3. Joint warmth and redness; functional toxicity impairment (b) Renal toxicity 4. Fatigue, depression (c) CNS toxicity—dizziness, anxiety, 5. Malaise, low-grade fever drowsiness, confusion (4) Drug interactions—may decrease ef- • Physical findings fectiveness of diuretics, beta-blockers, 1. Soft tissue swelling—most frequently in meta- ACE inhibitors; may increase toxicity carpophalangeal (MCP) and proximal inter- of lithium and methotrexate phalangeal (PIP) joints; usually symmetric (5) Contraindications/precautions—aspi- 2. Deformity of involved joints rin allergy; pregnancy category C, but 3. Limited range of motion in affected joint contraindicated third trimester; not 4. Subcutaneous nodules recommended while nursing 5. Lymphadenopathy b. Disease-modifying antirheumatic 6. Splenomegaly drugs—no analgesic effects; can control 7. Ocular disease—scleritis symptoms and may delay progression of 8. Entrapment neuropathies disease/representative list (1) Hydroxychloroquine—moderately • Differential diagnosis effective for mild RA (see SLE this 1. Polymyalgia rheumatica section) 2. Osteoarthritis (2) Sulfasalazine 3. Systemic lupus erythematosus (a) Side-effects—nausea, anorexia, 4. Ankylosing spondylitis rash; hepatitis, leukopenia, 5. Reiters syndrome agranulocytosis (b) Drug interactions—reduces ab- • Diagnostic tests/findings sorption of digoxin, folic acid 1. Rheumatoid (antibody) factor—can be iso- (c) Contraindication/precautions— lated in 70–80% of patients intestinal or urinary obstruction; 2. Elevated erythrocyte sedimentation rate pregnancy category B; not recom- 3. Radiography—joint erosion, narrowing of joint mended in nursing mothers space (3) Methotrexate (a) Side-effects—stomatitis, anorexia, • Management/Treatment nausea, abdominal cramps, in- 1. Nonpharmacologic creased aminotransferase activity a. Physical, occupational, hydrotherapy (b) Drug interactions—avoid other b. Rest hepatotoxic drugs, live virus c. Exercise vaccines d. Assistive devices (c) Contraindications/precautions— (1) Footwear—orthotics immunodeficiency, blood dys- (2) Canes, crutches crasias, alcoholism, chronic liver (3) Splints, braces disease; pregnancy category X; e. Surgery—synovectomy, arthroscopy not recommended in nursing 2. Pharmacologic mothers a. Nonsteroidal anti-inflammatory drugs (4) Leflunomide (NSAIDs)—initial choice (a) Side-effects—diarrhea, elevated (1) Agents liver enzymes, alopecia, rash (a) Ibuprofen, naproxen, diclofenac (b) Drug interactions—may increase (b) Meloxicam, etodolac, levels of diclofenac, ibuprofen; nabumetone Endocrine Disorders 293

caution with other hepatotoxic (3) Drug- or chemical-induced drugs 3. Complications (c) Contraindications/precautions— a. Macrovascular hepatic impairment; pregnancy (1) Coronary artery disease category X; not recommended in (2) Myocardial infarction; sudden cardiac nursing mothers death (5) Infliximab—given intravenously/used (3) Cerebrovascular disease with methotrexate (4) Peripheral vascular disease (a) Drug action—blocks activity of (5) Intestinal ischemia tissue necrosis factor (6) Renal artery stenosis (b) Side-effects—headache, aseptic b. Microvascular meningitis, infection, infusion re- (1) Retinopathy actions (fever, urticaria, dyspnea, (2) Nephropathy hypotension) and exacerbation (3) Peripheral neuropathy—parasthesias of CHF and glove and stocking neuropathy (c) Drug interactions—specific drug (4) Autonomic neuropathy—gastropare- interaction studies have not been sis and impotence conducted (d) Contraindications/precautions— • Etiology/Incidence/Risk factors CHF, active infection, live vac- 1. Type 1 cines; pregnancy category B; not a. Caused by autoimmune destruction of the recommended in nursing mothers pancreatic beta cells that produce insulin 3. Patient education (1) Genetic predisposition, a hypothetical a. Safety issues—footwear, balance, trans- triggering event, and immunologically- port, walking mediated beta cell destruction b. Discussion of long-term, chronic nature of (2) Typically begins in childhood or in disease, support network helpful young adults who are slim, but can c. Etiology—genetic component, occur in adults of any age noncontagious b. Manifested by absolute insulin deficiency d. Episodic nature of disease which results in elevation of blood glu- e. Pain control techniques—relaxation, drug cose, breakdown of fats and proteins therapy, rest, appropriate exercise c. Predisposition to development of ketoacidosis • Referral 2. Type 2 1. Physical therapy, occupational therapy a. Characterized by impaired insulin secre- 2. Surgical procedures tion, peripheral insulin resistance and increased hepatic glucose production Â Endocrine Disorders b. Typically occurs in those over 45, overweight and sedentary, with a family his- Diabetes tory of diabetes c. Racial/ethnic groups at increased risk— • Definition Native Americans, Hispanics, African 1. A heterozygous group of metabolic diseases Americans characterized by hyperglycemia resulting from 3. Gestational diabetes mellitus (GDM) defects in insulin secretion, insulin action, or a. Function of hormonal/metabolic de- both mands of pregnancy; usually regresses 2. Types after parturition a. Type 1—absolute insulin deficiency b. 50% risk of developing diabetes within b. Type 2—condition of fasting hyperglyce- 5 years if insulin was required for control mia despite availability of insulin of GDM; 60% risk of developing disease c. Gestational diabetes mellitus (GDM)— within 10 to 15 years if dietary manage- glucose intolerance diagnosed during ment was sufficient pregnancy 4. Impaired fasting glucose (IFG) and impaired d. Diabetes secondary to other causes glucose tolerance (IGT) (1) Genetic defects in beta-cell function/ a. Hyperglycemia not sufficient to meet diag- insulin action nostic criteria for diabetes (2) Diseases of the pancreas 294 Chapter 8 Nongynecological Disorders/Problems

b. Categorized as IFG if identified by fast- (2) A casual plasma glucose of 200 mg/dL ing blood glucose or IGT if identified by or greater with symptoms of diabetes; oral glucose tolerance test in the 2-hour or sample (3) An oral glucose tolerance test value c. Both categories are risk factors for diabe- of 200 mg/dL or greater in the 2-hour tes and cardiovascular disease sample 5. Prevalence in the general population esti- b. Categories of impaired glucose mated at 6–8% of individuals older than 40 metabolism: a. Type 1 accounts for approximately 10% of (1) Impaired fasting glucose—fasting diagnosed cases plasma glucose of 100–125 mg/dL b. Type 2 prevalence is estimated at more (2) Impaired glucose tolerance—results of than 14 million cases, many undiagnosed oral glucose tolerance test of 140–199 mg/dL in the 2-hour sample • Signs and symptoms 2. Criteria for screening asymptomatic adults 1. “Classic” symptoms—polyuria, polydipsia, (recommended screening test is fasting polyphagia plasma glucose) include (ADA, 2009): 2. Weight loss a. Anyone older than 45 years at 3-year 3. Fatigue and/or weakness intervals 4. Persistent/recurrent vaginal candidiasis; can- b. Consider testing younger than 45 years didal balanitis or more frequent screening in individuals 5. Vision changes, blurred vision with the following risks: 6. Type 2 often asymptomatic in early stages (1) Overweight—BMI of 25 or greater (2) First-degree relative with diabetes • Physical findings (parent, sibling) 1. Early (3) Member of a high-risk ethnic a. Thin, decreased weight/type 1; over- population weight, obese/type 2 (4) Delivered infant of greater than 9 b. Hypertension/type 2 pounds or history of GDM c. Skin infections—frequent or slow to heal (5) Hypertension 2. With more advanced disease (6) HDL cholesterol of 35 mg/dL or less a. Skin—ulcerations of feet and legs; loss of and/or triglyceride level of 250 mg/dL hair lower legs and toes or more b. Eyes—retinopathy/microaneurysms, (7) Previous IFG or IGT exudates, neovascularization; cataracts, (8) Other conditions associated with in- glaucoma sulin resistance—polycystic ovarian c. Cardiovascular—diminished or absent pe- syndrome ripheral pulses; orthostatic hypotension/ 3. Recommended glycemic goals for nonpreg- ominous finding nant patients (ADA, 2009) d. Neurologic—sensory loss; diminished/ a. Average preprandial plasma glucose absent deep tendon reflexes (mg/dL)—70 to 130 mg/dL b. Average peak postprandial glucose (1 to 2 • Differential diagnosis hours after beginning meal) of less than 1. Type 1 versus type 2 180 mg/dL

2. Pancreatic insufficiency c. HbA1c 3. Cushing’s syndrome (1) Reflects average glucose levels for the 4. Secondary effects of drug therapy—cortico- preceding 3 months steroids, thiazide diuretics (2) Goal of less than 7%—action suggested if greater than 8% • Diagnostic tests/findings 4. Tests helpful in identifying associated risk fac- 1. Criteria for diagnosis of diabetes (ADA, 2009) tors and complications include: a. Diabetes can be diagnosed in any one of a. Annual lipid profile, serum creatinine, three ways; must be confirmed on a sub- urinalysis sequent day b. Testing for microalbuminuria—2 of 3 tests (1) Fasting plasma glucose 126 mg/dL or measured over 6 months should be el- greater; fasting defined as no caloric evated before diagnosis intake for at least 8 hours; or Endocrine Disorders 295

(1) Test at time of diagnosis in type 2 dia- f. Perform comprehensive foot examination betics; after 5 years in type 1; annually annually; examination should include use thereafter of a Semmes-Weinstein monofilament, (2) Testing can be performed by three tuning fork, and a visual examination methods g. Annual influenza vaccination; pneumo- (a) Measurement of albumin-to- coccal vaccination creatinine ratio in a random, spot 3. Pharmacologic collection; microalbuminuria a. Type 1—insulin replacement 30–300 mg/mg creatinine; clinical (1) Insulin products/U-100 albuminuria of greater than 300 (a) Rapid acting (onset less than 0.5 mg/mg creatinine hour)—insulin lispro and insulin (b) 24-hour urine collection with aspart serum creatinine; values same as (b) Short acting (onset 0.5–1 spot urine hour)—regular (c) Timed collection such as 4 hours (c) Intermediate acting (onset 2–4 or overnight; microalbuminuria hours)—NPH, Lente 20–200 mg/min; clinical albumi- (d) Long acting—Ultralente/onset nuria of greater than 200 mg/min 6–10 hours; insulin glargine/onset c. Electrocardiogram at time of diagnosis 1–2 hours with no peak and periodically depending on symptoms (2) Intensive insulin treatment to achieve and risk factors tight control in highly motivated patients willing to perform multiple • Management/Treatment daily glucose determinations and ad- 1. Clinical trials have demonstrated that glyce- minister insulin according to results mic control is associated with decreased rates (a) Long acting insulin administered of microvascular complications; epidemiologic once/day in the evening; short studies support reduction in cardiovascular acting insulin administered 30–45 disease (ADA, 2009) minutes prior to meals, adjusted 2. Nonpharmacologic—Type 1 and 2 according to postprandial glucose a. Home glucose determinations to monitor measurements glycemic control daily (b) Consider use of rapid acting insu- b. Diet—individualized nutrition lin 10–15 minutes prior to meals recommendations in patients with hypoglycemic (1) Regulate carbohydrate intake (45–65% episodes of calories)—emphasis on complex (3) Consider less intensive treatment for carbohydrates rather than simple and patients unable to carry out intensive refined starches program; intermediate acting insu- (2) Regulate fat intake (< 30% of lin twice daily before breakfast and calories)—emphasis on polyunsatu- evening meal mixed with short acting rated instead of saturated fats in ratio insulin for prandial control of 2:1 b. Type 2—oral hypoglycemic agents (see (3) Maintain ideal body weight; corner- Table 8-6) stone of treatment for type 2 diabetic (1) Consider management with diet and c. Regular aerobic exercise exercise first; if glucose intolerance (1) Improves blood glucose control persists, begin oral agent (2) Reduces cardiovascular risk factors (2) Begin with second generation sulfo- (3) Contributes to weight loss nylurea or biguanide (metformin); d. Aggressively manage additional cardiovas- choose metformin if patient is obese cular risk factors (3) Increase dose every 1–2 weeks until (1) Blood pressure goal of less than glycemic control achieved or reach 125/75 maximum dose (2) LDL cholesterol of less than 70 mg/dL (4) If glycemic control not achieved with (3) Smoking cessation monotherapy, add second oral agent e. Refer type 2 diabetics at time of diagnosis from different class and type 1 diabetics within 3–5 years for eye examination; annually thereafter 296 Chapter 8 Nongynecological Disorders/Problems Precautions Contraindications/ Ketoacidosis, impaired renal, hepatic function; pregnancy category C; not recommended while nursing Renal disease or dysfunction, CHF requiring treatment; pregnancy Category B; use with caution while nursing Inflammatory bowel disease, or any intestinal disease causing disordered digestion or absorption; pregnancy category B; do not use while nursing Caution in hepatic impairment; pregnancy category C; not recommended in nursing mothers Hepatotoxicity—monitor q at start of therapy, LFTs 2 mo, first year; pregnancy category B; do not use while nursing Interactions Potentiated by NSAIDs, sulfonamides; antagonized by diuretics, beta-blockers, steroids, others potentiated by Effects cimetidine, ranitidine, nifedipine, digoxin, trimethoprim Charcoal, digestive enzymes will all decrease effect; of digoxin, decrease effects propranolol Potentiated by NSAIDs, alcohol; may be antagonized by thiazides, corticosteroids Possible drug interactions with oral contraceptives, ketoconazole, erythromycin, corticosteroids Side-effects Hypoglycemia, weight gain, GI upset, photosensitivity, cholestatic jaundice Anorexia, nausea, diarrhea, abdominal bloating; lactic acidosis—serious, rare Flatulence, diarrhea, abdominal discomfort (symptoms decrease over ALT time); increases AST, Hypoglycemia, headache, URI, dizziness Edema, headache, myalgia, URI; initial increase in LDL and HDL Action Stimulates insulin secretion from pancreatic beta cells Decreases hepatic glucose production and absorption of glucose; increases peripheral glucose uptake and utilization Delays absorption of carbohydrates, inhibits metabolism of sucrose to glucose and fructose Stimulates insulin release from pancreas Improves insulin sensitivity, glucose uptake in muscle and adipose tissue; inhibits gluconeogenesis Oral Medications Used to Treat Type 2 Diabetes Mellitus (representative list) Type Oral Medications Used to Treat Drug 1st generation— chlorpropamide 2nd generation— glipizide, glyburide, glimepiride Metformin Acarbose, Miglitol repaglinide, nateglinide rosiglitazone, pioglitazone Table 8-6 â Table Â Sulfonylureas â â â â Biguanides— â a -glucosidase inhibitor— â Meglitinides— â Thiazolidinediones— â Endocrine Disorders 297

(5) Consider insulin in patients unable (2) Hyperglycemia to achieve glycemic control with two (a) Nausea, vomiting, mental confu- oral agents or initially in symptomatic sion, fruity breath odor patients with fasting blood glucose (b) Immediate administration of greater than 240 mg/dL insulin c. Use aspirin therapy in all adult diabetic patients with macrovascular complica- • Referral tions and diabetic patients older than 40 1. All newly diagnosed cases for complete years with any other cardiovascular risk evaluation factors (American Diabetes Association, 2. Evaluation of suspected or developing 2009) complications d. Use ACE inhibitors in patients with microalbuminuria or clinical albuminuria Hypoglycemia (see Table 8-1) 4. Patient education • Definition—a nonspecific diagnosis often charac- a. Family involvement in care, medication terized by vague symptoms of malaise, fatigue, or instruction headache, attributed to either adrenergic excess or b. Safety concerns, especially compensation insufficient CNS glucose; symptoms can become for neuropathies severe c. Assure compliance with drug regimen (1) Appropriate injection technique for • Etiology/Incidence insulin 1. Etiology (2) Importance of regular dosing, oral or a. Adrenergic excess parenteral b. Insufficient central nervous system glu- d. Blood glucose monitoring cose—fasting or exercise-induced (1) Routine schedule and glycemic target c. Medication-induced—oral hypoglycemic values agents, insulin (2) Aseptic technique for blood sampling 2. Incidence unknown due to difficulty in estab- (3) Medication dosage calculation based lishing diagnosis on blood glucose e. Risk factor management and screening • Signs and symptoms (1) Smoking cessation if appropriate 1. Adrenergic excess (2) Annual comprehensive eye examina- a. Sweating tion with ophthalmologist b. Tremor (3) Foot care c. Hunger (4) Dental hygiene and annual d. Anxiety examination e. Palpitations (5) Nutritional counseling with registered 2. Neuroglycopenia dietitian a. Irritability, personality changes (6) Contraception and preconceptional b. Headache counseling emphasizing optimal glu- c. Blurred, double vision cose control d. Confusion f. Signs of hypo/hyperglycemia and method e. Lethargy, stupor, coma of management (1) Hypoglycemia • Physical findings (a) Sweating, palpitations, anxiety, 1. Adrenergic—tachycardia, tremor mood changes 2. Neuroglycopenia—stupor, coma (b) Treat with 6-oz glass of orange juice, hard candy, teaspoon of • Differential diagnosis honey; glucose tablets 1. Insulinoma (c) Parenteral administration 2. Extrapancreatic tumors—adrenal, hepatic, sar- of glucagon by caregiver or coma, mesothelioma family member in event of 3. Hypopituitary disorder unconsciousness 4. Addison’s disease 5. Massive liver disease 298 Chapter 8 Nongynecological Disorders/Problems

• Diagnostic tests/findings Hyperthyroidism 1. Depressed blood glucose levels accompanied by typical symptoms • Definition—a hypermetabolic syndrome affecting a. Men, less than 50 mg/dL all body systems characterized by excess circulat- b. Women, less than 40 mg/dL ing thyroid hormone 2. C-peptide assay a. Principle use is evaluation of • Etiology/Incidence hypoglycemia 1. Etiology b. Elevated C-peptide levels with endog- a. Graves’ disease enous hyperinsulinism or insulinoma; de- (1) Comprises 90% of cases creased C-peptide levels with surreptitious (2) Autoimmune condition; excess insulin injection synthesis and secretion of thyroid hormone caused by antibodies that • Management/Treatment stimulate thyroid stimulating hor- 1. Nonpharmacologic mone (TSH) receptors a. Alimentary hypoglycemia (3) Often self-limited; symptomatic 1–2 (1) Limit high-glycemic-index carbohy- years drates; include a low-glycemic-index b. Toxic multinodular goiter—accounts for carbohydrate at every meal most cases in middle-aged and elderly (a) Glycemic index (GI) is a measure c. Toxic adenoma/solitary autonomous of the effect of carbohydrate- nodule—single hyperfunctioning nodule containing foods on blood surrounded by suppressed thyroid tissue glucose d. Thyroiditis—group of inflammatory (b) Low-glycemic-index foods diseases lower risk of causing relative (1) Inflammation causes disruption of hypoglycemia the follicles resulting in release of pre- (c) Examples of low GI foods—apple, formed thyroid hormone pear, milk, kidney beans, pasta (2) Usually self-limited (d) Examples of high GI foods— (3) Phases—thyrotoxicosis, transient eu- baked potato, white bread, bagel, thyroid, hypothyroid, recovery white rice (4) Classification of thyroiditis (2) Smaller, more frequent meals (a) Subacute lymphocytic—autoim- (3) Weight reduction if obese mune process b. Acute episodes—oral administration of i. Postpartum thyroiditis simple carbohydrate if fasting, drug- ii. Painless/sporadic thyroiditis induced, or exercise-induced (b) Subacute granulomatous/ c. Reducing caffeine intake sometimes de Quervain’s thyroiditis—likely helpful viral in origin and generally pre- d. Surgical—removal of insulinoma, other ceded by URI tumors 2. Incidence 2. Pharmacologic a. Annual incidence 0.05–1% in general adult a. Anticholinergic/propantheline population (1) Drug action—delay gastric emptying b. Hyperthyroidism is 5–10 times more com- (2) Side-effects—anticholinergic effects mon in females (3) Drug interactions—increases effects c. Postpartum thyroiditis occurs in 8–10% of of digoxin women within 1 year of delivery (4) Contraindications/precautions— acute angle-closure glaucoma; preg- • Signs and symptoms—nonspecific, affecting all nancy category C body systems; reflect increased stimulation from b. Beta-blocker/propranolol (see Table 8-1) excess thyroid hormone 3. Patient education 1. Increased appetite, weight loss a. Individualized dietary counseling 2. Irritability, nervousness, sleep disturbance b. Symptom recognition 3. Heat intolerance, sweating 4. Fatigue, exertional shortness of breath • Referral 5. Palpitations, tremor 1. When tumor or other underlying disease is 6. Diarrhea suspected 7. Decreased menses 2. If symptoms not relieved by dietary changes Endocrine Disorders 299

8. Eye irritation, vision changes, double vision Graves’ in young adults, pregnant women, (Graves’) before surgery and RAI ablation (1) Drug action • Physical findings (a) Block multiple steps in the syn- 1. Thyroid gland—enlarged/diffuse or asymmet- thesis of thyroid hormone ric nodularity (b) Permanent remission in half of 2. Neuromuscular system—hyperreflexia, patients and one fourth of these tremor, muscle wasting hypothyroid in 15–20 years 3. Dermatologic system—skin moist, smooth (c) Clinically euthyroid in 4–8 weeks 4. Cardiovascular system—tachycardia, systolic (2) Side-effects flow murmur, atrial fibrillation in elderly (a) Dermatitis, myalgias 5. Eyes—lid retraction (b) Leukopenia—monitor CBC 6. Gastrointestinal system—increased bowel (c) Agranulocytosis—cannot be sounds predicted; instructions to notify 7. Graves’ disease healthcare provider if fever or sore a. Symmetrical and moderate thyroid throat enlargement/bruit (d) Hepatocellular damage—monitor b. Exophthalmos/proptosis and pretibial LFTs myxedema (nonpitting thickening of skin) (3) Drug interactions—potentiates oral 8. Toxic multinodular goiter—asymmetric anticoagulants nodularity (4) Contraindications/precautions—

9. Toxic adenoma—single nodule surrounded by pregnancy category D, monitor FT4 suppressed thyroid tissue every 2 to 4 weeks and use lowest 10. Thyroiditis—slight enlargement; tender with doses to maintain euthyroid; con- subacute granulomatous thyroiditis traindicated while nursing b. Radioactive iodine therapy—treatment of • Differential diagnosis choice for toxic multinodular goiter and 1. Neoplasm—because of associated weight loss toxic adenoma; preferred treatment for and weakness most adults older than 40 2. Psychological disorders—panic disorder (1) Drug action (a) Damages functioning thyroid • Diagnostic tests/findings tissue 1. Ultrasensitive serum thyroid stimulating hor- (b) Reduces symptoms in 6–12 weeks mone (TSH) (2) Side-effects a. Most effective initial test for diagnosis (a) Long-term hypothyroidism; 70% b. Low in response to excess circulation thy- of patients at 10 years roid hormone (b) May exacerbate ophthalmopathy

2. Free T4 usually elevated in the short term

3. Serum T3 elevated—useful when T4 normal, (3) Contraindications—pregnancy or TSH low, and patient is symptomatic lactation 4. Radioactive iodine scan with uptake c. Beta-blockers—propranolol, atenolol (see a. Scan/anatomic definition Table 8-1) b. Radioactive iodine uptake/hyper- versus (1) Decreases signs and symptoms by hypofunction blocking sympathetic nervous system (1) Uptake diffusely increased in Graves’ (2) Indicated for symptomatic relief until (2) Uptake decreased in thyroiditis more specific therapy initiated (3) Hot nodule with little uptake in rest of d. Management of thyroiditis—often no gland in toxic adenoma treatment required (1) Beta-blockers for symptomatic treat- • Management/Treatment ment of thyrotoxicosis 1. Nonpharmacologic (2) Subacute granulomatous thyroiditis a. Diet—increased need for calories (a) NSAIDs for pain/inflammation b. Decrease stimulants (b) Prednisone for extreme cases (see 2. Pharmacologic Table 8-3) a. Antithyroid drugs—propylthiouracil, 3. Patient education methimazole/preferred treatment of a. Medication regimens, side-effects 300 Chapter 8 Nongynecological Disorders/Problems

b. Signs/symptoms of thyroid storm—an • Physical findings—depend on severity, duration of exaggeration of signs and symptoms of deficiency, and rapidity of development hyperthyroidism; requires immediate 1. Thyroid gland may be atrophic, normal, or attention goitrous 2. Neuromuscular system—diminished relax- • Referral ation phase of reflexes, carpal tunnel syn- 1. Radioactive iodine treatment; consider referral drome, hearing loss for treatment with antithyroid drugs 3. Dermatologic system—skin cool, dry; hair dry, 2. Ophthalmologist referral for ophthalmopathy brittle; generalized hair loss, especially outer 3. Refer for surgical consideration patients third of eyebrows with obstructive symptoms and/or cosmetic 4. Cardiovascular system—bradycardia; edema, concerns especially periorbital, anemia 5. Gastrointestinal system—mild weight gain, Hypothyroidism diminished bowel sounds 6. Endocrine system—galactorrhea • Definition—a metabolic syndrome affecting all organ systems characterized by deficient levels of • Differential diagnosis circulating thyroid hormone 1. Primary versus secondary 2. Clinical depression • Etiology/Incidence/Risk factors 3. Antithyroid drugs—lithium 1. Etiology a. Primary thyroid failure • Diagnostic tests/findings (1) Hashimoto’s thyroiditis—chronic au- 1. TSH—elevated in primary hypothyroidism

toimmune thyroiditis 2. Free T4—decreased

(2) Previous radioactive iodine treatment, 3. Decreased TSH and FT4 in secondary surgery hypothyroidism b. Secondary—pituitary or hypothalamic 4. Antithyroid peroxidases, antithyroglobulin, disease and antimicrosomal antibodies—Hashimoto’s c. Transient thyroiditis (1) Subacute granulomatous thyroiditis/ 5. Hypercholesteremia de Quervain’s (2) Subacute lymphocytic thyroiditis/ • Management/Treatment postpartum and sporadic painless 1. Nonpharmacologic 2. Prevalence estimated 1–3% of general a. Restrict calories if needed for weight population control a. Increasing prevalence with age and in b. High-fiber, low-fat diet women 2. Pharmacologic (primary b. Women older than 50 years have esti- hypothyroidism)—levothyroxine

mated 5% prevalence a. Drug action—synthetic T4

3. Risk factors (1) T4 converted to T3; administration of

a. Age older than 50 years T4 produces both hormones b. Female-to-male ratio is 8 to 10:1 (2) Half-life 6 days; slow rate of achieving c. History of autoimmune disease steady state d. Family or personal history of thyroid (3) Adjust dose every 6 weeks until TSH disease normalizes b. Side-effects—symptoms of • Signs and symptoms—often subclinical; re- hyperthyroidism/excess replacement flect slowed physiologic functioning of all organ c. Drug interactions systems (1) Potentiates sympathomimetics 1. Weakness, lethargy (2) Monitor antihyperglycemics, oral 2. Skin changes—dry or coarse skin, skin pallor; anticoagulants coarse hair d. Contraindications 3. Slow speech, forgetfulness, depression (1) Thyrotoxicosis 4. Cold sensation, decreased sweating (2) Acute MI 5. Eyelid, facial edema (3) Uncorrected adrenal insufficiency 6. Constipation 7. Irregular menses—menorrrhagia, amenorrhea; infertility Musculoskeletal Disorders 301

3. Patient education (1) L5 root/L4–5 disc—pain/numbness a. Medication use and doses; need for long- lateral calf term therapy (2) S1 root/L5-S1 disc—pain buttocks, b. Danger of increasing medication too rap- lateral leg and malleolus; numbness idly or taking more than prescribed lateral foot and posterior calf 3. Spinal stenosis—pain precipitated by walking • Referral—all secondary cases for evaluation or standing upright; relieved by sitting or lean- ing forward Â Musculoskeletal Disorders • Physical findings Low Back Pain (LBP) 1. Lumbosacral strain a. Increased pain with flexion • Definition—acute (< than 3 months), chronic, or b. Negative straight leg raise (SLR); normal recurrent pain occurring in the lumbosacral spine neurologic exam region; pain may be localized or radiate to the 2. Herniated intervertebral disc extremities a. Increased pain with flexion b. Positive SLR—radicular pain when leg is • Etiology/Incidence passively raised 30–60° 1. Etiology c. L5 root—weakness dorsiflexion of great a. No specific identifiable cause in up to 85% toe; decreased sensation anterior/medial of cases; lumbosacral strain results from dorsal foot stretching, tearing of muscles, tendons, d. S1 root—weakness of plantar flexion/tip- ligaments, and fascia due to trauma or re- toe walking; diminished/absent Achilles petitive mechanical stress reflex; decreased sensation lateral foot b. Herniated intervertebral disc causing 3. Spinal stenosis—assessment of lower ex- nerve root compression resulting in pain tremities for loss of hair, color, and pulses to below the knee and other neurologic signs differentiate spinal stenosis from vascular and symptoms insufficiency c. Spinal stenosis—soft tissue or bony encroachment of the spinal canal and nerve • Differential diagnosis roots 1. Cauda equina syndrome 2. Incidence a. Surgical emergency due to impingement a. One of the top 10 reasons for visit to pri- on the cauda equina mary care provider b. Characterized by saddle anesthesia, b. Estimated 65–80% of individuals experi- bladder or bowel incontinence, muscle ence at least one episode weakness c. Women and men equally affected 2. Fracture—major trauma such as motor vehicle d. Chronic LBP comprises about 2% of all or fall from high place cases 3. Osteoporosis/compression fracture—may be 3. Risk factors—acute LBP precipitated by minor trauma or lifting a. Repetitive motion 4. Neoplasm—constitutional symptoms, no relief b. Poor body mechanics with bedrest, chronic pain c. Sedentary lifestyle; poor strength of ab- 5. Infection—chills, fever, IV drug user, recent dominal and back muscles bacterial infection, immunosuppression

• Signs and symptoms • Diagnostic tests/findings 1. Lumbosacral strain 1. Indicated in the presence of “red flags”—fever, a. Pain located in the back, buttocks, or one chills, weight loss, recent onset bladder/bowel or both thighs dysfunction, lower extremity sensory or neuro- b. Pain aggravated by standing/flexion; re- logic deficit lieved with rest/reclining 2. Radiograph of lumbosacral spine 2. Herniated intervertebral disc a. Generally not necessary in acute a. Characterized by radicular pain; paresthe- phase—3–6 weeks duration sias may occur in distribution of involved b. Suspicion of fracture nerve root c. Suspicion of malignancy—patient older b. Most common disc ruptures involve the than 50 years; persistent bone pain unre- L5 or S1 nerve roots lieved by bed rest; history of malignancy 302 Chapter 8 Nongynecological Disorders/Problems

3. MRI or CT Osteoarthritis a. Severe persistent symptoms despite conservative treatment • Definition b. Suspected disc herniation 1. Noninflammatory joint disease characterized by degeneration of articular cartilage with new • Management/Treatment bone formation at articular surface 1. Nonpharmacologic 2. Most commonly involved joints are distal and a. Encourage continuation of daily activities proximal interphalangeals of hands, hips, rather than bedrest knees, and cervical and lumbar spine b. Local application of heat, warm baths 3. Primary—no obvious cause c. Prescribe physical therapy program to im- 4. Secondary—occurring in damaged or abnor- prove strength and conditioning mal joints d. Low stress aerobic exercise—walking, bik- ing, swimming • Etiology/Incidence/Risk factors 2. Pharmacologic 1. Etiology a. Nonsteroidal anti-inflammatory drugs a. Progressive degeneration and loss of ar- (NSAIDs) (see Acute Otitis Media this ticular cartilage and subchondral bone chapter)—ibuprofen, naproxen, etodolac b. Bone ends thicken and osteophytes or b. Muscle relaxant—cyclobenzaprine spurs form where the ligaments and cap- (1) Drug action—reduces tonic somatic sule attach to the bone motor activity in the brain stem c. Variable synovial inflammation results (2) Side-effects—somnolence, dry mouth 2. Incidence (3) Drug interactions—hypertensive crisis a. Radiographic evidence in 80% of adults by with MAOIs; potentiates alcohol and age 60 other CNS depressants b. Clinical osteoarthritis affects approxi- (4) Contraindications/precautions— mately 25% of adults acute post-MI, arrhythmias; preg- 3. Risk factors nancy category B; precaution in a. Increasing age nursing mothers b. Female gender 3. Patient education c. Obesity a. Avoid bedrest d. Major joint trauma b. Weight loss if indicated to reduce e. Repetitive joint stress lordosis f. Congenital and developmental joint c. Good body mechanics; proper lifting defects d. Appropriate exercises g. Metabolic and endocrine disorders e. Signs of deterioration (1) Loss of bladder control • Signs and symptoms (2) Numbness or weakness in groin or 1. Gradual onset of joint pain, tenderness, and rectal area limited movement (3) Pain extending down leg past knee 2. Pain aggravated by joint use and subsides with f. Reassurance rest (1) Excellent prognosis for complete reso- 3. Morning joint stiffness or stiffness following a lution of acute LBP episodes period of inactivity, lasting generally less than (2) Recurrence likely at variable 30 min intervals 4. Symptoms often asymmetrical

• Referral • Physical findings 1. Urgently refer patients with symptoms sugges- 1. Decreased range of motion tive of cauda equina or cord compression 2. Effusions of involved joint(s) with minimal lo- 2. Symptoms suggestive of spinal infection or cal warmth and no erythema malignancy 3. Enlargement of distal interphalangeal (DIP) 3. Neurologic consultation if back pain remains joints—Heberden’s nodes; enlargement severe after 4–6 weeks of conservative treat- of proximal interphalangeal (PIP) joints— ment or findings of neurologic deficits Bouchard’s nodes 4. Crepitus with joint motion Musculoskeletal Disorders 303

• Differential diagnosis a. Symptomatic relief techniques, e.g., cold, 1. Rheumatoid arthritis heat, immobilization, rest 2. Infectious arthritis b. Medication regimens and precautions 3. Tendonitis/bursitis syndromes 4. Crystal induced arthritis—gout, pseudogout • Referral 5. Fracture a. Physical therapy, exercise b. Need for joint injection • Diagnostic tests/findings c. Surgery consultation—joint replacement 1. Radiography a. Will not demonstrate deterioration of Osteoporosis cartilage b. Four cardinal radiologic features • Definition—disease characterized by low bone (1) Narrowed joint space mass and structural deterioration of bone tissue, (2) Sclerosis of subchondral bone leading to bone fragility and an increased suscep- (3) Bony cysts tibility to fractures of the hip, spine, and wrist (Na- (4) Osteophytes tional Institute of Health) 2. Diagnostic joint fluid aspiration a. Indicated if joint effusion • Etiology/Incidence b. Synovial fluid analysis—white blood cell 1. Combination of factors including nutrition, count with differential; culture; evaluation genetics, level of physical activity, age of for crystals menopause, and estrogen status c. Findings in osteoarthritis—WBC count 2. 8 million American women and 2 million men less than 2000 cells/ml; negative culture; have osteoporosis negative for crystals 3. Accounts for more than 1.5 million fractures 3. Laboratory—normal in primary osteoarthritis annually (70% women) a. Rheumatoid factor (RF)/antinuclear anti- 4. Cost for hospital and nursing home stays for bodies (ANA)—if arthritis is inflammatory osteoporosis-associated fractures in excess of and symmetrical in distribution to exclude $10 billion annually rheumatoid arthritis or systemic lupus 5. Risk factors include: erythematosus (SLE) a. Female gender b. Erythrocyte sedimentation rate—elevated b. Advanced age in many autoimmune, inflammatory, in- c. Thin and/or small body frame fectious diseases d. Positive family history c. CBC—if an inflammatory or infectious ar- e. Caucasian or Asian thritis suspected f. Menopause g. Estrogen deficiency • Management/Treatment h. Calcium and/or vitamin D deficiency 1. Nonpharmacologic i. Use of certain medications—corticoste- a. Appliances, e.g., canes, crutches, orthotics roids, anticonvulsants, heparin b. Exercise—walking, swimming, stationary j. Sedentary lifestyle cycling k. Cigarette smoking c. Rest during acute exacerbations l. Excessive alcohol use d. Supervised heat and cold therapy e. Weight loss if indicated • Signs and symptoms 2. Pharmacologic 1. Often a silent disease a. Nonsteroidal anti-inflammatory drugs 2. Backache (NSAIDs) as described for LBP 3. Spontaneous fracture or collapse of vertebrae b. Intra-articular injection (1) Glucocorticoids—beneficial in pa- • Physical findings tients with inflammation, effusion, or 1. Loss of height substantial pain 2. Kyphosis (2) Synovial fluid analog—sodium 3. Fractures—spine, hip, wrist hyaluronate/hylan G-F20; usefulness documented in knee joints; safety in • Differential diagnosis other joints not documented 1. Malignancy—bone neoplasms, metastatic car- 3. Patient education cinoma, multiple myeloma 2. Osteomalacia 304 Chapter 8 Nongynecological Disorders/Problems

3. Paget’s disease • Management/Treatment 4. Secondary causes of osteoporosis include 1. Nonpharmacologic—prevention and a. Hyperparathyroidism treatment b. Hyperthyroidism a. Adequate intake of calcium and vitamin c. Cushing’s syndrome D—see Menopause section of Chapter 3 b. Regular weight-bearing exercise • Diagnostic tests/findings (1) 30 minutes 3 to 4 times each week 1. Bone mineral density (BMD) tests (2) Walking, stair climbing, dancing a. World Health Organization definitions c. Regular muscle strengthening exercise— based on bone mass measurement in lifting weights, swimming women include: d. Avoidance of tobacco use and alcohol (1) Normal—BMD within 1 standard de- abuse viation (SD) of a young normal adult; e. Fall prevention strategies—correct im- T-score above –1 paired vision, assess medications for po- (2) Osteopenia (low bone mass)—BMD tential to cause orthostatic hypotension, between 1 and 2.5 SD below that of a supportive low heeled shoes, assistive de- young normal adult; T-score between vices if needed (cane, walker), home safety –1 and –2.5 measures (3) Osteoporosis—BMD 2.5 SD or more 2. Pharmacologic or below that of a young normal adult; a. Consider pharmacologic treatment for T-score at or below –2.5 postmenopausal women presenting with b. Dual-energy x-ray absorptiometry any of the following (National Osteoporo- (DEXA)—most widely used; quick; radia- sis Foundation, 2008): tion exposure one tenth of standard chest (1) Hip or vertebral fracture radiograph; body sites measured—hip, (2) T-score of –2.5 or less at the femoral spine, wrist neck or spine after appropriate evalu- c. Single-energy x-ray absorpitometry ation to exclude secondary causes (SXA)—small, portable; body sites mea- (3) T-score between –1.0 and –2.5 at fem- sured—forearm, finger, heel oral neck or spine and 10-year prob- d. Quantitative ultrasound (QUS)—recently ability of hip fracture of 3% or greater; developed, radiation-free technique using or a 10-year probability of major os- the transmission of high frequency sound teoporotic related fracture of 20% or waves; small and portable; body sites greater based on FRAX measured—heel, finger, tibia, radius b. Hormone therapy (HT)—may be consid- e. Quantitative computed tomography ered short term (5 years) for prevention if (QCT)—measures trabecular and cortical needs treatment for vasomotor symptoms bone density; body site measured—mainly and/or vulvovaginal atrophy; not ap- spine proved for treatment of existing osteo- 2. Standard radiography—20–30% bone loss porosis (see Menopause section of must occur for osteoporosis detection; used to Chapter 3) detect osteoporotic fractures c. Bisphosphonates—alendronate/ 3. Laboratory tests if indicated to rule out sec- risedronate—indicated for prevention ondary causes of osteoporosis—parathyroid and treatment; ibandronate—oral form hormone (PTH) level, TSH, dexamethasone approved for prevention and treatment, suppression test and urine cortisol level for intravenous form approved for treatment; Cushing’s syndrome zoledronic acid—intravenous form 4. Additional skeletal health assessment approved for treatment techniques (1) Drug action—osteoclast mediated a. Biochemical markers for bone turnover bone resorption inhibitor—bone for- b. Vertebral fracture assessment mation exceeds bone resorption lead- c. Fracture risk algorithm (FRAX)—devel- ing to progressive gains in bone mass oped to calculate 10-year probability of (2) Side-effects—GI upset, abdominal hip fracture and 10-year probability of a pain, esophagitis, musculoskeletal major osteoporotic fracture taking into ac- pain, headache count femoral neck BMD and clinical risk (3) Drug interactions—antacids and cal- factors cium interfere with absorption (4) Contraindications/precautions— esophageal stricture, inability to Musculoskeletal Disorders 305

stand/sit upright for at least 30 min- (1) Baseline BMD before onset of therapy utes, hypocalcemia, pregnancy risk (2) Repeat test every 2 years; more fre- category C; check serum creatinine quently if warranted by certain clinical before each ibandronate injection situations (5) Client instructions (3) Urine/serum biochemical markers of (a) Take with 8 oz of water in the bone formation or resorption may be morning at least 30 minutes used as adjunct to monitor response before any beverage, food, or to therapy—variable results and preci- medication sion error limit usefulness; changes (b) Do not lie down for at least 30 must be large in order to be clinically minutes and until the first food of meaningful the day 3. Patient education (c) May take acetaminophen prior a. Adequate calcium and vitamin D intake to zoledronic acid injection to b. Weight-bearing and muscle strengthening reduce risk of postinjection arth- exercises ralgia, headache, myalgia, fever c. Avoidance of tobacco and excessive d. Selective estrogen receptor modulators alcohol (SERM)—raloxifene—indicated for pre- d. Fall prevention strategies vention and treatment e. Medication use (1) Drug action—estrogenlike effects on bones and lipid metabolism; lacks es- Fibromyalgia trogenlike effect on uterus and breasts (2) Side-effects—hot flashes, leg cramps, • Definition venous thromboembolic events (rare) 1. A syndrome characterized by chronic fatigue, (3) Drug interactions—may antagonize generalized musculoskeletal pain and stiffness warfarin associated with the finding of characteristic (4) Contraindications—women who are tender points of pain on physical examination pregnant or may become pregnant; 2. Criteria for the classification of fibromyalgia active or history of venous throm- a. Widespread pain for more than 3 months boembolic events; do not give with b. Pain on palpation in at least 11 of 18 se- estrogen or cholesterol lowering lected tender points medication e. Calcitonin-salmon—indicated for treat- • Etiology/Incidence ment only 1. Etiology—unknown, but classified as a rheu- (1) Drug action—directly inhibits bone matic disease; several causal mechanisms resorption of calcium; administered as postulated a nasal spray or injection a. Physical or mental stress (2) Side-effects—nasal spray-rhinitis, GI b. Sleep disturbances upset; injection-GI upset, local in- c. Decreased serotonin levels flammation, rash, flushing d. Metabolic factors (3) Drug interactions—none reported e. Viral infection—Epstein-Barr virus, cyto- (4) Contraindications—hypersensitivity megalovirus, herpes virus, enteroviruses to salmon calcitonin, pregnancy risk 2. Incidence—unknown in general population category C due to misdiagnosis, self-treatment f. Terparatide—approved for treatment if a. More common in women, with a 9:1 high risk for fracture female/male ratio (1) Drug action—anabolic bone building b. Most common in 30 to 50 year olds agent, parathyroid hormone; administered as subcutaneous injection • Signs and symptoms (2) Side-effects—leg cramps, dizziness 1. Multiple, specific areas of muscle tenderness (3) Drug interactions—none reported (“trigger points”) (4) Contraindications/precautions— 2. Fatigue, sleep disturbances avoid if increased risk of osteosar- 3. Muscle weakness and generalized aching coma, prior radiation of skeleton, 4. Pain typically worsens with cold bone metastases, hypercalcemia 5. Paresthesias g. Monitoring pharmacologic therapy 6. Headaches effectiveness 7. Anxiety, stress 8. Depression 306 Chapter 8 Nongynecological Disorders/Problems

• Physical findings C; not recommended in nursing 1. Pain on digital palpation of characteristic ten- mothers der points 3. Patient education 2. Normal muscle strength, range of motion a. Reassurance regarding benign course of condition • Differential diagnosis b. Supportive care for chronic pain 1. Chronic fatigue syndrome 2. Rheumatoid arthritis • Referral—physical therapy 3. SLE 4. Somatization and depression Strains/Sprains

• Diagnostic tests/findings • Definition—musculoskeletal injury of varying 1. Unnecessary unless a coexisting condition is degrees suspected 1. Strain refers to injury to muscle or tendon 2. Erythrocyte sedimentation rate normal; ex- 2. Sprain refers to stretching or tearing of cludes inflammatory conditions ligaments

• Management/Treatment • Etiology/Incidence 1. Nonpharmacologic 1. Etiology a. Low impact exercise, e.g., walking, a. Overuse of the muscle–tendon unit by swimming stretching, tearing, hyperextension, force- b. Supervised heat and cold therapy ful contraction c. Massage, relaxation therapy b. Acute injury d. Biofeedback c. Chronic overuse as seen in sports injury, e. Hypnotherapy repetitive motion f. Strength training 2. Incidence—unknown due to frequent self- 2. Pharmacologic treatment, but common presenting complaint a. Mild analgesics in primary care practice b. Selective serotonin and norepinephrine 3. Risk factors reuptake inhibitors—duloxetine a. Increased physical activity c. Tricyclic antidepressants for sleep b. New physical exercise program disturbance—amitryptyline c. Overweight d. Pregabalin (1) Drug action—binds to calcium chan- • Signs and symptoms nels on nerves and may modify the 1. Pain at site of injury release of neurotransmitters 2. Strain (2) Side-effects—dizziness, somnolence, a. Temporary weakness other central nervous system effects b. Pain with stretch of muscle (3) Contraindications/precautions— c. Pain and spasm with more severe strains avoid abrupt cessation; pregnancy 3. Sprain category C; not recommended in a. Marked swelling nursing mothers b. Loss of function e. Tramadol (1) Drug action—centrally acting analge- • Physical findings sic; creates a weak bond to opioid re- 1. Strain—temporarily reduced range of motion, ceptors and inhibits reuptake of both muscle strength norepinephrine and serotonin 2. Sprain (2) Side-effects—drowsiness, dizziness, a. Contusion, hemorrhage headache, nausea, and constipation b. Reduced range of motion, muscle strength (3) Drug interactions—seizure risk with c. Joint instability in severe sprain or rup- other agents that lower threshold/ tured ligament MAOIs, SSRIs; potentiated with alcohol and other CNS depressants • Differential diagnosis (4) Contraindications/precautions— 1. Other overuse syndromes—tendonitis, shin abuse potential; pregnancy category splints 2. Fracture Neurologic Disorders 307

• Diagnostic tests/findings factors—hormonal fluctuations, 1. Radiograph to rule out fractures—negative for weather changes, diet, psychoso- bony abnormality in strains/sprains cial disruptions 2. MRI (c) Changes in serotonin activity result in release of vasoactive • Management/Treatment mediators; mediators produce an 1. Nonpharmacologic inflammatory response adjacent a. “RICE”—initial therapeutic strategy to cerebral blood vessels accom- (1) Rest or immobilization of injured part panied by vasodilation (2) Ice or application of cold (d) The dilated vessels and inflam- (3) Compression, elastic wrap matory response stimulate the (4) Elevation of affected area trigeminal nerve to transmit im- b. Application of heat 24 to 36 hours after pulses to the brain resulting in injury migraine headache c. Topical heat-generating liniments for (2) Tension headache symptomatic relief (a) Pathophysiology poorly under- 2. Pharmacologic stood; formerly attributed to a. Usually none indicated, not curative contraction of the muscles of the b. NSAIDs as for acute LBP scalp and neck 3. Patient education (b) Recent theories suggest tension a. Physical training progression to avoid re- headaches may involve changes peat injury in the intracranial neurotransmit- b. Stretching and warm-up exercises ter and vascular systems similar c. Appropriate footwear, protective gear for to migraine exercise (c) Symptom complex resulting from several simultaneous processes— • Referral muscle tension, psychological 1. Physical therapy for stretching and strengthen- stress, neurovascular changes ing program (3) Cluster headache 2. Consult orthopedic surgeon if no response to (a) Secondary to serotonergic neuro- conservative management logic dysfunction (b) Clustering of attacks suggests in- Â Neurologic Disorders volvement of circadian pacemak- ers of the anterior hypothalamus Headaches (c) Tearing and nasal stuffiness suggests abnormality in autonomic • Definition nervous system 1. Headache/cephalagia is defined as diffuse b. Secondary headaches pain in various parts of the head (1) Vascular disorders—subarachnoid, 2. Primary headaches—migraine, tension, cluster cerebral, cerebellar hemorrhage; acute headaches are not directly related to a specific ischemic cerebrovascular disorder; AV underlying cause or secondary to another malformation; temporal arteritis; arte- problem rial HTN 3. Secondary headaches are the result of identifi- (2) Nonvascular intracranial disorders— able structural or physiologic pathology neoplasm; infection; low cerebrospinal fluid pressure/post lumbar • Etiology/Incidence/Risk factors puncture; benign intracranial HTN/ 1. Etiology pseudotumor cerebri a. Primary headaches—90–98% of head- (3) Traumatic—concussion and postcon- aches presenting in primary care cussion; hematoma/subdural and (1) Migraine headache epidural (a) Current understanding suggests (4) Metabolic disorders—hypoxia, hyper- genetic basis capnia, hypoglycemia (b) Those genetically predisposed (5) Substances that act as triggers— inherit a nervous system that is medications; foods/MSG, alcohol; more sensitive/easily aroused exposures/carbon monoxide; to a variety of internal/external rebound/caffeine, analgesics 308 Chapter 8 Nongynecological Disorders/Problems

(6) Extracranial structures—eyes/ (6) Changes in weather or barometric glaucoma, refractive errors; sinusitis; pressure temporomandibular joint dysfunc- d. Location—unilateral tendency tion; neck/cervical disk disease; e. Duration—4–72 hours trigeminal neuralgia f. Character (7) Systemic—infection; allergies/pollen; (1) Moderate to severe intensity; inhibits hormonal daily activities 2. Incidence (2) Characterized as throbbing, pounding a. Migraine g. Associated symptoms—nausea, vomiting, (1) Reported in up to 15–17% of women; photophobia, phonophobia, fatigue 5% of men h. Frequency—recurrent, variable from two (2) Estimated 10% of adults affected to three per year to two to three per week b. Tension—lifetime prevalence of 90%; 2. Tension headache yearly prevalence 80–90% a. Onset—gradual c. Cluster—relatively rare incidence com- b. Location—diffuse, bilateral, generalized pared to other types; six times more com- c. Duration—variable, hours to days mon in males d. Character 3. Risk factors—primary headache syndromes (1) Mild to moderate severity; generally a. Migraine headaches—female gender, fam- able to continue with daily activities ily history (2) Dull, pressure, constant, vise-like b. Tension headaches—overuse of headache e. Associated symptoms—fatigue, irritability, medications difficulty concentrating, neck and shoul- c. Cluster headaches—male, middle-aged or der spasm older f. Frequency (1) Episodic—less than 15 days per • Signs and symptoms month 1. Migraine (2) Chronic—must be present 15 days or a. Types more a month for at least 6 months (1) Migraine with aura/classic migraine 3. Cluster headaches (a) Aura consists of focal neurologic a. Onset symptoms that may precede or (1) Abrupt accompany headache (2) Often nocturnal, awakens patient; of- (b) Usually visual phenomenon; ten recurs at same time of day flashing lights, zigzag/jagged b. Location lines, difficulty focusing (1) Unilateral (2) Migraine without aura/common (2) During a series, pain remains on same migraine—accounts for 75% of side migraines (3) Retro-orbital, sometimes radiating (3) Complicated migraine—basilar/ c. Duration—usually 30 to 45 minutes hemiplegic migraine d. Character—intense, severe b. Phases e. Associated symptoms—facial pain, ptosis (1) Prodrome—occurs 24 hours prior to of the affected side, lacrimation, nasal onset of headache: fatigue, euphoria, congestion difficulty concentrating, irritability f. Frequency—occurs in clusters lasting a (2) Aura few weeks with remission lasting weeks to (3) Early and late stages of migraine months (4) Postdrome—individual feels “wiped out,” fatigued, “hung-over” • Physical findings c. Triggers 1. General appearance indicates discomfort (1) Stress 2. Neurologic assessment normal in primary (2) Hormonal changes headaches—occasional temporary focal neu- (3) Certain foods, caffeine, alcohol, skip- rologic findings with migraine ping meals 3. Blood pressure, vital signs normal (4) Fatigue, oversleeping 4. Cluster headache—unilaterally constricted (5) Medications pupil, nasal discharge Neurologic Disorders 309

• Differential diagnosis—“red flags” suggesting sec- iii. Side-effects—tightness of the ondary causes throat/chest, flushing, numb- 1. Headache beginning after 50 years of age— ness, tingling, dizziness; temporal arteritis, mass lesion side-effects tend to abate with 2. Sudden onset, worst headache—subarachnoid time hemorrhage iv. Drug interactions—should 3. Headaches increasing in severity/frequency— not be used within 24 hours mass lesion, subdural hematoma, medication after another triptan or any overuse ergotamine-containing drug 4. Focal neurologic signs/papilledema v. Contraindications/ 5. Headache subsequent to head trauma— precautions—coronary artery intracranial hemorrhage, subdural/epidural disease, hypertension; preg- hematoma, posttraumatic headache nancy category C; caution in 6. Systemic illness/fever—meningitis/ lactation encephalitis (c) Second line—ergotamines i. Agents—ergotamine, dihy- • Diagnostic tests/findings droergotamine/parenteral 1. None indicated when examination is consis- and nasal spray tent with primary headache syndromes ii. Drug action—nonspecific 2. Erythrocyte sedimentation rate on all patients serotonin agonist and with new onset older than 40 years to rule out vasoconstrictor temporal arteritis iii. Side-effects—nausea/ 3. CT/MRI vomiting (premedicate with a. Indicated if persistent focal neurologic anti-emetic), tachycardia, findings or history of trauma vasoconstriction b. CT preferred to identify acute hemorrhage iv. Drug interactions—do not c. MRI more sensitive in identifying patho- give with triptan logic intracranial changes v. Contraindications/ d. Magnetic resonance angiography if an- precautions—coronary artery eurysm suspected—history of exertional disease, hypertension; preg- headaches nancy category X; not recommended while nursing • Management/Treatment (2) Prophylactic therapy—consider in pa- 1. Nonpharmacologic tients who experience more than two a. Regular sleep and meal schedules severe headaches per month, need b. Daily exercise acute treatment medication more c. Avoiding known triggers than two times per week or are unable 2. Pharmacologic to tolerate abortive agents a. Migraine (a) Beta-blocker—propranolol/ (1) Abortive therapy timolol (see Table 8-1) (a) First line therapy—mild-to- (b) Calcium channel blockers—verap- moderate intensity amil (see Table 8-1) i. NSAIDs, acetaminophen (c) Anti-epileptic agents—valproic (see Acute Otitis Media this acid (see Table 8-7) chapter) b. Tension ii. Excedrin migraine—aspirin, (1) Episodic acetaminophen, caffeine/59% (a) NSAIDs, acetaminophen (see efficacy at 2 hours Acute Otitis Media this chapter) (b) First line therapy—moderate-to- (b) Caffeine, butalbital, acetamino- severe intensity—triptans phen (Fioricet) and caffeine, aspi- i. Agents—sumatriptan, zolmi- rin (Fiorinal) triptan, naratriptan, rizatrip- i. Drug action—butalbital is a tan, almotriptan, frovatriptan; barbiturate; muscle relaxant available in oral, nasal, SC at lower doses, hypnotic at forms higher doses ii. Drug action—selective sero- ii. Side-effects—drowsiness, tonin agonists lightheadedness, nausea, vomiting 310 Chapter 8 Nongynecological Disorders/Problems Contraindications Liver disease; acute angle-closure glaucoma; pregnancy category C; not recommended for nursing mothers Acute myopia and secondary angle-closure glaucoma, hepatic or renal impairment, kidney stones; pregnancy category C Pregnancy category D; do not use while nursing; liver disease or dysfunction History of bone marrow depression; pregnancy category D; do not use while nursing Heart block, sinus bradycardia; pregnancy category D; not recommended while nursing Interactions -blockers; other AED 2 Antagonizes oral contraceptives, digoxin, oral anti-coagulants; potentiated by benzodiazepines, estrogens, H Potentiates CNS depression with alcohol; antagonized by phenytoin, carbamazepine Potentiates CNS depression with alcohol; potentiates phenobarbital, phenytoin; antagonized by carbamazepine, phenobarbital, phenytoin, valproic acid, verapamil Potentiates phenobarbital, phenytoin Increased plasma levels with CYP3A4 inhibitors-INH, macrolides; decreased plasma levels with CYP3A4 inducers- phenytoin Side-effects Nystagmus, drowsiness, ataxia, diplopia, gingival hyperplasia, hirsutism, low folate level Fatigue, sedation, behavior changes—aggressiveness and confusion Drowsiness, dizziness, ataxia, fatigue, visual disorders Nausea, vomiting, sedation, blood dyscrasias Sedation, GI upset, ataxia, blurred vision, skin rash, aplastic anemia Action prevents spread of seizure from hyperactive focus depresses nerve transmission in motor cortex neurotransmitter GABA, which on has an inhibitory effect seizures channels from their inactivated state; inhibits sustained repetitive firing Commonly Used Anti-epileptic Drugs (AED) (representative list) Drug Table 8-7 â Table Â Phenytoin Stabilizes membranes and Topiramate Enhances GABA action Clonazepam Enhances GABA action; Valproic acidValproic Increased brain levels of Carbamazepine Delays recovery of sodium Neurologic Disorders 311

iii. Drug interactions—poten- a. Think of seizure as positive phenomenon tiation with alcohol, CNS such as movement versus negative phe- depressants nomenon such as paralysis in transient iv. Contraindications/ ischemic attack (TIA) precautions—hepatic impair- b. Where the discharge arises and how far it ment; pregnancy category C; spreads determines what the seizure looks not recommended in nursing like clinically mothers 2. Classification of seizures (2) Chronic a. Partial seizures occur within localized (a) Tricyclic antidepressants (TCAs)— regions of the brain; result of a localized amitriptyline, nortriptyline physiologic or structural abnormality in i. Action—increases synaptic the brain concentration of serotonin (1) Simple partial—consciousness not and norepinephrine in CNS impaired ii. Side-effects—sedation, dry (2) Complex partial—consciousness mouth, blurred vision, con- impaired stipation, abnormal cardiac (3) Partial with secondary generalization conduction, dysrhythmias b. Generalized seizures arise from both sides iii. Drug interactions—additive of the brain simultaneously anticholinergic effects (1) Tonic-clonic (formerly “grand mal”) iv. Contraindications—with (2) Absence (formerly “petit mal”) MAOI, impaired liver func- (3) Myoclonic tion; pregnancy category (4) Atonic C; not recommended while nursing • Etiology/Incidence (b) Selective serotoin reuptake inhibi- 1. Etiology tors—less effective than TCAs (see a. First step in evaluation of suspected sei- Depression this chapter) zure is to determine whether event was a 3. Patient education seizure a. Signs indicating need for emergency b. Once event identified as a seizure, need to treatment determine if epilepsy or secondary to an- (1) Acute fever with headache other medical problem—hypoxia, hypo- (2) Abnormal mental status or personality glycemia, infection, fever, toxic substance changes abuse (3) Sudden onset; worst headache c. Epilepsy is characterized by recurrent experienced seizures; can be secondary to inherited or (4) Neurologic symptoms, e.g., projectile acquired factors emesis, visual disturbances (1) Head injury b. Self-medication for abortive therapy, (2) Brain tumor injections (3) Cerebrovascular events c. Education regarding nonpharmacologic (4) Idiopathic management—avoidance of precipitating 2. Incidence factors a. Recurrence rate widely variable, linked to etiology • Referral b. Complex partial seizures most common 1. Focal neurologic findings adult type 2. Specific secondary diagnosis is suspected c. Absence seizures most common in 3. Chronic headaches develop new features childhood 4. New headaches in individuals older than 50 3. Risk factors years a. Inherited neurologic disease b. History of trauma Seizure Disorders c. In persons with known seizure disorders (1) Sleep deprivation • Definition (2) Unusual stresses 1. Sudden change in body functioning with or (3) Menstruation without loss of consciousness due to an abnor- (4) Medications/drugs mal discharge of neurons 312 Chapter 8 Nongynecological Disorders/Problems

• Signs and symptoms • Physical findings 1. Partial seizures 1. Often no physical findings a. Simple partial 2. Focus physical examination on cardiovascular (1) Lasts 5–10 seconds and neurologic systems (2) No loss of consciousness; no postsei- a. Normal neurologic examination found in zure confusion patients with idiopathic seizures (3) Symptoms reflect focal area of brain b. Focal neurologic findings—brain lesion affected (a) Jerking or shaking in one area • Differential diagnosis of body; may progress as focus 1. Vascular events, e.g., transient ischemic attack spreads along cortical motor strip (TIA), classic migraine (b) Somatosensory symptoms 2. Syncope (c) Visual or auditory symptoms 3. Hyperventilation/anxiety attacks (d) Autonomic symptoms—sweating, 4. Narcolepsy epigastric discomfort 5. Psychogenic spells, e.g., transient global (e) Psychic symptoms amnesia b. Complex partial (1) Duration—5–10 seconds; 1–2 minutes; • Diagnostic tests/findings rarely more than 5 minutes 1. Electrolytes, glucose, BUN/creatinine, LFTs, (2) Loss of consciousness; postseizure calcium, magnesium confusion 2. Toxicology screen (3) Blank stare followed by an automa- 3. CBC tism, e.g., lip smacking, picking at 4. Lumbar puncture if infection is a clothing, purposeless walking consideration 2. Generalized seizures—always involve loss of 5. CT can detect bleeding or gross structural consciousness lesions a. Tonic-clonic seizures (grand mal) 6. MRI is study of choice; more sensitive and spe- (1) Tonic phase—all skeletal muscles con- cific for evaluating structural lesions and brain tract and patient falls parenchyma (2) Clonic phase 7. EEG (a) Repetitive motor activity of all a. Used to establish presence and type of extremities epilepsy (b) As clonic phases abate muscles b. Initial EEG abnormal in only 40% of pa- become flaccid and incontinence tients with probable epilepsy can occur (3) Postictal period • Management/Treatment (a) Consciousness may not return for 1. Nonpharmacologic—avoidance of triggers 10–15 minutes 2. Pharmacologic (see Table 8-7) (b) Confusion, headache and fatigue a. Principles may last from hours to days (1) Goal—complete suppression of b. Absence seizure seizures (1) Duration—5–10 seconds; may cluster (2) Initial treatment—single drug (2) Manifest with blank stare, eye blinking (3) Blood levels should be monitored (3) No postseizure confusion periodically c. Myoclonic seizure (4) When adding a second drug, main- (1) Quick, involuntary muscle jerks last- tain the first drug, titrating dosages ing a few seconds involving one body after second drug reaches therapeutic part or entire body levels (2) May accompany other generalized (5) Treatment withdrawal should not be seizures; common to specific epilepsy considered until seizure-free for a syndromes minimum of 2 years d. Atonic b. Pharmacologic management by seizure (1) Sudden loss of postural tone causing type patient to fall (1) Partial seizures—carbamazepine, (2) Often associated with other seizure phenytoin, topiramate types; common in Lennox-Gastaut (2) Generalized seizures syndrome Dermatologic Disorders 313

(a) Tonic-clonic seizures—phenytoin, 2. Incidence carbamazepine, valproic acid, a. Affects up to 90% of teens; 15% have topiramate moderate-to-severe acne (b) Absence—valproic acid, b. May persist to older than 40 years in some, ethosuximide especially women (c) Myoclonic—valproic acid, 3. Risk factors clonazepam a. Aggravated by stress, hormonal cycling (d) Atonic—clonazepam b. Use of topical steroids 3. Patient education c. Contact with irritant oils or cosmetics a. Pregnancy and contraception d. More common and more severe in males (1) Impact on seizure frequency, severity variable • Signs and symptoms (2) Teratogenic effects of seizure 1. Erythematous lesions, sometimes tender medications 2. May be episodic, cyclic in severity (3) Decreased oral contraceptive efficacy 3. Distribution and severity tends to be similar in with many antiseizure medications; family members select backup or alternative method b. Safety issues regarding recurrent seizures • Physical findings (1) Activity limitations, e.g., driving 1. Lesions occur primarily on the face, but neck, (2) Possible need for protective wear shoulders, chest and back may be involved (3) Household hazards identification and 2. Mild—open and closed comedones without modification inflammation c. Medication schedules and side-effects 3. Moderate—comedones with papules and pustules • Referral 4. Severe—comedones, papules and pustules 1. All clients with first-time seizures with nodules, cysts and scarring 2. Uncontrolled seizures 3. For EEG and interpretation • Differential diagnosis 4. Suspected underlying metabolic disease, neu- 1. Rosacea ral lesion 2. Pyoderma 5. Pregnancy care 3. Drug eruptions 4. Underlying endocrine disease—polycystic Â Dermatologic Disorders ovarian syndrome, Cushing’s syndrome 5. Folliculitis Acne 6. Perioral dermatitis

• Definition—a common self-limited disease that • Diagnostic tests/findings—none indicated presents with a variety of lesions including open and closed comedones, papules and pustules, • Management/Treatment nodules, and cysts 1. Nonpharmacologic—cleansing 2. Pharmacologic • Etiology/Incidence a. Mild acne—topical medications 1. Etiology (1) Benzoyl peroxide a. Primary cause is obstruction of the pilose- (a) Drug action—antibacterial and baceous follicle comedolytic properties b. Characterized by plugging of the hair (b) Side-effects follicle with abnormally cohesive i. Skin irritation desquamated cells, sebaceous gland hy- ii. Allergic dermatitis peractivity, proliferation of bacteria iii. May bleach clothing/bed (P. acnes), and inflammation linens, hair c. Obstruction of follicle leads to develop- (c) Drug interactions—PABA sun- ment of noninflammatory acne—closed screens may temporarily discolor comedones/white heads and open come- skin dones/black heads (d) Contraindications/precautions d. Proliferation of P. acnes/rupture of follicle i. Avoid eyes, mouth, mucous wall results in inflammatory acne with membranes papules, pustules, nodules, cysts 314 Chapter 8 Nongynecological Disorders/Problems

ii. Pregnancy category C; pre- (c) Drug interactions—reduced ab- caution in nursing mothers sorption with antacids (2) Retinoic acid derivatives—tretinoin/ (d) Contraindications/precautions— cream, gel, lotion, and microspheres; pregnancy Category D; not rec- adapalene gel/solution; tazarotene gel ommended in nursing mothers (a) Drug action—comedolytic agent (3) Oral contraceptives—some have FDA (b) Side-effects—local irritation, ery- approval for treatment of moderate thema, scaling acne in women who also desire con- (c) Drug interactions—concomitant traception; all with low androgenic use with benzoyl peroxide may or antiandrogenic progestin are likely cause skin irritation effective (d) Contraindications/precautions (a) Drug action—antiandrogenic/ i. Avoid UV light, sun, extreme decreases free testosterone avail- weather able for metabolism in sebaceous ii. Do not use with eczema glands iii. Pregnancy category C; not (b) Side-effects recommended while nursing i. Nausea, vomiting (3) Azelaic acid ii. Minor bleeding irregularities, (a) Drug action—antibacterial and headaches normalizes keratinization iii. Hypertension (b) Side-effects iv. Thromboembolic events i. Local irritation, itching, con- (c) Drug interactions—antagonized tact dermatitis by hepatic enzyme inducing ii. Depigmentation drugs, e.g., griseofulvin, rifampin (c) Drug interactions—none (d) Contraindications identified i. Thromboembolic disorders (d) Contraindications/precautions— ii. Known or suspected estrogen- pregnancy category B; caution in dependent neoplasm nursing mothers iii. History of cardiovascular or b. Moderate acne—topical antibiotics cerebrovascular disease (1) Topical antibiotics—clindamycin, iv. Pregnancy category X; not erythromycin recommended in nursing (a) Drug action—bactericidal effects mothers (b) Side-effects c. Severe acne—isotretinoin i. Local irritation (1) Drug action—decreases size and se- ii. Folliculitis cretion of sebaceous glands, normal- (c) Drug interactions—additive effect izes follicular keratinization, inhibits with other topical agents P. acnes, and modulates the inflamma- (d) Contraindications/precautions tory response i. Avoid eyes, mucous (2) Side-effects membranes (a) Liver function test abnormalities ii. History of regional enteritis, (b) Anemia, depression ulcerative or antibiotic- (c) Skin and mucosal dryness induced colitis/clindamycin (d) Tendonitis iii. Pregnancy category B/C; not (e) Lipid abnormalities, pancreatitis recommended while nursing (3) Drug interactions (2) Oral medications—tetracycline, doxy- (a) Tetracyclines may increase inci- cycline, minocycline; erythromycin, dence of pseudotumor cerebri azithromycin (b) Avoid alcohol (a) Drug action (tetracycline and its (c) Vitamin A derivatives)—antibacterial and (4) Contraindications/precautions— anti-inflammatory effect Pregnancy category X; not recom- (b) Side-effects mended while nursing i. GI effects 3. Patient education ii. Photosensitivity a. Use of mild cleansers, noncomedogenic iii. Yeast infections moisturizers, sunscreen Dermatologic Disorders 315

b. “Hands off” policy to avoid secondary in- b. Linear eruption is the hallmark of most fection, scarring plant dermatoses c. Importance of avoiding pregnancy if using 3. Distribution often provides clues to diagnosis isotretinoin • Differential diagnosis • Referral—severe acne; may refer patients requiring 1. Atopic dermatitis, eczema treatment with isotretinoin 2. Tinea 3. Scabies/pediculosis Contact Dermatitis 4. Herpes simplex/Herpes zoster

• Definition—skin inflammation due to irritants (ir- • Diagnostic tests/findings ritant contact dermatitis) or allergens (allergic con- 1. Usually none indicated tact dermatitis) 2. Negative potassium hydroxide (KOH) preparation of skin scraping • Etiology/Risk factors 3. Patch testing with suspected allergens in dif- 1. Etiology ficult cases a. Irritant contact dermatitis (1) Eczematous response that is nonal- • Management/Treatment lergic caused by irritants including 1. Nonpharmacologic chemicals, dry and cold air, and a. Compresses, soaks, e.g., Burow’s solution, friction Epsom salts (2) May occur acutely, more commonly b. Lubricants—lubricating ointments, petro- occurs after chronic exposure latum, no creams b. Allergic contact dermatitis 2. Pharmacologic (1) A manifestation of cell-mediated hy- a. Topical corticosteroids—intermediate persensitivity; causes delayed reaction potency for mild/moderate dermatitis; on first exposure hydrocortisone for face/groin (2) Rhus plant antigens (poison oak, poi- (1) Drug action—anti-inflammatory son ivy) will result in clinical eruption effect in 12–72 hours and within minutes on (2) Side-effects reexposure (a) Local irritation (3) Other common allergic sensitizers (b) Epidermal and dermal atrophy include nickel (jewelry), rubber com- (3) Drug interactions—none identified pounds (gloves), cosmetics, topical (4) Contraindications/precautions medications (a) Avoid prolonged use on large 2. Risk factors areas a. Irritant contact dermatitis (b) Pregnancy category C; not recom- (1) Everyone at risk; people vary in mended while nursing response b. Systemic steroids for widespread or severe (2) Frequent exposure; chronic exposure dermatitis (see Table 8-3) b. Allergic contact dermatitis—genetically c. Antihistamines—allergic pruritus predisposed reaction (1) Hydroxyzine (a) Drug action—antihistamine • Signs and symptoms (b) Side-effects—drowsiness, dry 1. Report of recent exposure (within 24 hours) to mouth known allergens; exposure to irritants (c) Drug interactions—potentiates 2. Pruritus CNS depression with alcohol, other CNS depressants • Physical findings (d) Contraindications—early preg- 1. Irritant contact dermatitis nancy; nursing mothers a. Mild irritants cause erythema, dryness, (2) Cetirizine (see Table 8-2) fissuring 3. Patient education b. Chronic exposure may cause oozing, a. Avoidance of allergens weeping lesions b. Protective garments, gloves 2. Allergic contact dermatitis a. Classic lesions are vesicles and blisters on erythematous base 316 Chapter 8 Nongynecological Disorders/Problems

Skin Cancer a. Lesions seen in sun-exposed areas or skin damaged by burns or chronic inflamma- • Definition—malignant neoplasms arising in skin tion; lower lip lesions common cells b. A skin lesion that does not heal 3. Malignant melanoma • Etiology/Incidence/Risk factors a. Changing nevus; change in color, diameter 1. Etiology increase, or border change a. Basal cell carcinoma (BCC) b. Pruritus is early symptom (1) Slow growing, rarely metastasizes, c. Bleeding, ulceration, discomfort are late but may cause extensive local tissue signs damage (2) Tumor arises in basal layer of epider- • Physical findings mis; causes include chronic sun expo- 1. Basal cell—several clinical variants; nodular sure and genetic predisposition basal cell most common b. Squamous cell carcinoma (SCC) a. Waxy, semitranslucent nodule with rolled (1) Directly attributable to sun exposure borders or chronic irritation b. Central ulcerations; telangectasias (2) 60% occur at site of previous actinic 2. Squamous cell keratoses a. Red/reddish brown plaque/nodule (3) Low tendency for metastasis b. Surface is scaly/crusted with erosions or c. Malignant melanoma (MM) ulcerations (1) Arises from cells of the melanocyte 3. Malignant melanoma—tends to have Asym- system; begins either de novo or de- metry, Border irregularity, Color variations and velops from preexisting lesion Diameter greater than 6 mm (ABCD) (2) Initially grows superficially and later- a. Superficial spreading type/70%—pro- ally; enters vertical growth phase with longed horizontal growth phase; vertical potential to metastasize growth occurs later 2. Incidence b. Nodular—raised, pigmented (blue, black, a. Basal cell approximately 75% all skin dark brown, gray) nodules with normal cancers surrounding skin b. Squamous cell second most common skin c. Acral lentiginous—found on palms, soles, cancer in whites; most common skin can- nail beds, mucous membranes cer in blacks d. Lentigo melanoma—occurs in preexisting c. Malignant melanoma represents 1% of lentigo maligna skin cancers; 60% of skin cancer deaths 3. Risk factors • Differential diagnosis a. Nonmelanoma skin cancers 1. Common melanocytic nevus (1) Cumulative sun exposure; higher inci- 2. Seborrheic keratosis dence in outdoor workers 3. Dermatofibroma (2) White race; fair complexion that burns easily/tans poorly • Diagnostic tests/findings—biopsy (3) Advancing age (4) Male gender • Management/Treatment (5) Previous history of skin cancer 1. Nonpharmacologic/pharmacologic b. Malignant melanoma a. Excision and biopsy of lesions (1) History of changing mole b. Basal cell carcinoma/squamous cell carci- (2) Family and or personal history of noma—treatment options melanoma (1) Mohs’ micrographic surgery—gradual (3) History of nonmelanoma skin cancer lesion excision using serial frozen sec- (4) Atypical nevus syndrome tion analysis and mapping of excised (5) Fair complexion; tendency to sunburn tissue until tumor-free plane reached (2) Cryotherapy • Signs and symptoms (3) Curettage with electrodesiccation/ 1. Basal cell—painless, slow-growing lesion on freezing exposed areas c. Malignant melanoma 2. Squamous cell (1) Excision of lesion (2) Lymph node dissection Dermatologic Disorders 317

(3) Adjunctive therapy—chemotherapy, 2. Incidence radiation, excision of metastasis a. Scalp infections more common in children (4) Long-term follow-up b. Affects males/females about equally 2. Patient education—focused on prevention c. Intertriginous infections common in a. Reduce exposure young adults (1) Avoid sun exposure d. Tinea pedis clinically apparent in 5–10% of (2) Use of sunscreen with sun protective population factor (SPF) of 15 or greater 3. Risk factors (3) Protective clothing a. Tinea capitis—overcrowding and poor (4) Educate regarding risk of tanning hygiene salons b. Tinea cruris—hot, humid conditions, oc- b. Educate regarding the acronym ABCD; clusive clothing useful reminder of the clinical features c. Tinea unguium—aging, diabetes, poorly that should raise suspicion of melanoma fitting shoes, and tinea pedis in a pigmented lesion c. Total cutaneous examination (TCE)—rec- • Signs and symptoms ommended annually for populations with 1. May be asymptomatic risk factors 2. Itching, burning variable (1) Complete visual inspection of skin, scalp, hands and feet for any suspi- • Physical findings cious lesions 1. Classic presentation is a lesion with central (2) Include questions regarding risk, ex- clearing surrounded by an advancing, red posures, family history scaly, elevated border (3) Best preventive practice to reduce 2. Scalp lesions characterized by hair loss/scaling mortality 3. Maceration, especially intertriginous lesions d. Self-examination for lesions, changing 4. Involved nails are yellowish/thickened with nevi subungual debris

• Referral for ongoing care (chemotherapy, • Diagnostic tests/findings immunotherapy) 1. Potassium hydroxide (KOH) microscopy positive for hyphae Tinea 2. Fungal culture for specific identification 3. Wood’s lamp of limited usefulness; most • Definition dermatophytes currently seen in US do not 1. Superficial fungal infection caused by fluoresce dermatophytes 2. Dermatophytes require keratin for growth; in- • Management/Treatment fection restricted to hair, superficial skin, and 1. Nonpharmacologic nails a. Careful nail and skin care 3. Classified according to involved anatomic b. Keep area dry, absorbent clothing location 2. Pharmacologic a. Tinea capitis—scalp; mainly affects a. Topical antifungals—tinea corporis, tinea children cruris, tinea pedis b. Tinea corporis—body (1) Azoles—clotrimazole, econazole, ke- c. Tinea cruris—upper inner thigh/spares toconazole, miconazole scrotum (a) Drug action—fungicidal activity d. Tinea pedis—toe webs; soles/heels (b) Side-effects—pruritus, irritation, e. Tinea unguium—toenails more frequently stinging involved than fingernails (c) Drug interactions—none identified • Etiology/Incidence/Risk factors (d) Contraindications/precautions— 1. Etiology pregnancy category C; not recom- a. Microsporum, Trichophyton, Epidermo- mended in nursing mothers phyton species (2) Allylamines—naftifine, terbinafine b. Transmission via contact with infected (a) Drug action—fungicidal activity persons, fomites (shoes, towels, shower (b) Side-effects—burning, stinging, stalls), animals, or soil irritation, dryness 318 Chapter 8 Nongynecological Disorders/Problems

(c) Drug interactions—none Â Psychosocial Problems identified (d) Contraindications/precautions— Stress pregnancy category B; precaution in nursing mothers • Definition—Selye’s Theory of Stress Response and b. Oral antifungals—tinea capitis, tinea Adaptation describes a continuum related to stress unguium 1. Eustress or good stress—degree of stress that (1) Griseofulvin is motivating and viewed as positive for the (a) Drug action—interferes with fun- individual gal microtube formation by dis- 2. Distress—point at which stress becomes psy- rupting mitosis and cell division chologically or physically debilitating (b) Side-effects—headache, nausea, vomiting, diarrhea, • Etiology/Incidence photosensitivity 1. Major life events—marriage, divorce, job (c) Drug interactions—reduces effec- change, death of a family member tiveness of oral contraceptives 2. Chronic situations—poverty, illness of self or (d) Contraindications/precautions— family member, abuse porphyria, hepatocellular failure, 3. Acute situations—acute pain, sudden threats pregnancy; precaution in nursing to safety mothers 4. Environmental conditions—noise, pollution, (2) Itraconazole overcrowding (a) Drug action—decreases ergos- 5. Daily hassles—minor events that occur on a terol synthesis inhibiting cell regular basis membrane formation (b) Side-effects—GI upset, rash, • Signs and symptoms fatigue, headache, dizziness, 1. Irritability, anxiety, depression, chronic edema; hepatitis reported/ worrying monitor LFTs 2. Decreased productivity, sleep disturbances, (c) Drug interactions—inhibits drug appetite changes, loss of libido metabolizing enzymes/CYP3A4; 3. Vague or nonspecific physical complaints— may increase levels of other drugs headaches, nausea, diarrhea, chest pain, mus- (d) Contraindications/precautions— cle tension hepatic dysfunction; pregnancy Category C; not recommended in • Physical findings nursing mothers 1. Muscle tension (3) Terbenafine 2. Increase in blood pressure (a) Drug action—inhibits enzyme activity in fungi; inhibits synthesis • Differential diagnosis of ergosterol 1. Depression (b) Side-effects—GI distur- 2. Anxiety disorders bances, headaches; rare LFT 3. Other medical conditions that could account abnormalities for signs and symptoms (c) Drug interactions—potentiated by cimetidine; antagonized by • Diagnostic tests/findings—none rifampin (d) Contraindications/precautions— • Management/Treatment liver or renal disease; pregnancy 1. Eliminate or modify stressors—assertiveness category B; not recommended in training, time management, positive thought nursing mothers strategies, communication skills 3. Patient education 2. Relaxation techniques—guided imagery, mus- a. Keep skin dry as possible, especially inter- cle relaxation exercises, biofeedback, massage, trigal spaces meditation, use of humor, physical exercise b. Wear loose, clean, absorbent clothing c. Contagious nature of condition Anxiety

• Definition—DSM-IV-TR lists several psychiatric syndromes of which anxiety is a primary Psychosocial Problems 319

component; interference with everyday function b. Apprehension—insomnia, difficulty must be present to classify anxiety as a psychiatric concentrating syndrome c. Cardiac symptoms—palpitation, chest 1. Generalized anxiety disorder tightness, or pain a. Persistent, excessive, incapacitating worry d. Respiratory symptoms—difficulty breath- over life events ing, feelings of suffocation b. Anxiety and worry are associated with e. Gastrointestinal symptoms—nausea, diar- three or more of the following symp- rhea, dry mouth toms—restlessness, easily fatigued, dif- f. Neurologic symptoms—weakness, tingling ficulty concentrating, irritability, muscle numbness in extremities, dizziness tension, sleep disturbance g. Feelings of panic and/or loss of control 2. Panic disorder h. Other—excessive sweating, feeling of a. Intense, brief, acute anxiety; often no tightness in throat precipitant b. Four of the following symptoms—palpi- • Physical findings tations, sweating, trembling, shortness 1. Physical findings may be present with an acute of breath, choking sensation, chest pain, anxiety attack abdominal distress, dizziness, derealiza- 2. Tachycardia, increased respirations, elevated tion, fear of losing control, fear of dying, BP paresthesias, chills/hot flashes 3. Restlessness c. May occur with or without agoraphobia 4. Diaphoresis 3. Agoraphobia—anxiety about, or avoidance 5. Muscle tension of, places or situations in which the ability to leave suddenly may be difficult in the event of • Differential diagnosis having a panic attack 1. Medical conditions that may account for 4. Specific phobia—anxiety elicited by a discrete symptoms of anxiety—cardiac arrhythmias, stimulus such as heights or specific animals mitral valve prolapse, angina, pulmonary 5. Social phobia—fear of social and performance embolism, hypoglycemia, hyperthyroidism, situations that is excessive or incapacitating asthma, chronic obstructive pulmonary dis- 6. Posttraumatic stress disorder (PTSD)—delayed ease, Cushing’s disease, pheochromocytoma and persistent anxiety that follows an ex- 2. Medication-induced symptoms of anxiety— tremely traumatic event steroids, anticholinergics, sympathomimetics, 7. Acute stress disorder (ASD)—similar to PTSD digoxin, thyroxine but more immediate and of shorter duration 3. Drug abuse or withdrawal 8. Obsessive-compulsive disorder (OCD)— 4. Other psychological disorders—depression, characterized by obsessions that cause marked bipolar disorder anxiety or distress and/or by compulsions that serve to neutralize the anxiety • Diagnostic tests/findings 1. May be done to exclude other medical condi- • Etiology/Incidence tions suggested by history/physical 1. Approximately 15% of individuals will experi- 2. Screen for occult hyperthyroidism with TSH ence an anxiety disorder in their lifetime 2. Generalized anxiety disorder is the most com- • Management/Treatment mon type 1. Nonpharmacologic—psychotherapy/cognitive 3. Several neuroregulators have been implicated behavioral therapy in the cause of anxiety, e.g., dopamine, sero- 2. Pharmacologic—choice of medications de- tonin, norepinephrine pends on type of anxiety disorder 4. Conditioned learning may also play a role in a. Generalized anxiety disorder the development of anxiety disorders (1) Benzodiazepines for period of exacerbation—lorazepam, diazepam, • Signs and symptoms clonazepam 1. Clinical presentations vary with each anxiety (a) Drug action—produce an anti- category anxiety effect by enhancing the 2. Most clients with an anxiety disorder will pre- action of the neurotransmitter sent with some combination of the following: gamma-aminobutyric acid at the a. Motor tension—restlessness, jitteriness cortical and limbic areas of the brain 320 Chapter 8 Nongynecological Disorders/Problems

(b) Side-effects—sedation, impaired • Etiology/Incidence/Risk factors concentration anterograde amne- 1. At least 20% of women will experience depres- sia; dependence; abuse potential sion in their lifetime (c) Drug interactions—potentiates 2. Onset is highest between the ages of 20 and 40 the effect of other CNS depres- 3. Also occurs in adolescent and elderly sants including alcohol; may populations be potentiated by use with 4. Theories include biologic, sociologic, and neu- cimetidine roendocrine etiologies (d) Contraindications—pregnancy 5. Risk factors for depression include: category D a. Prior incident of major depression (2) SSRI—paroxetine, venlafaxine, sertra- b. Family history of depression line (see Depression this chapter) c. Severe or chronic illness/chronic pain (3) Serotonin and norepinephrine d. Marital or family problems including reuptake inhibitors (SNRI)—dulox- abuse etine, venlafaxine (see Depression this e. Substance or alcohol abuse chapter) f. Postpartum period (3) Buspirone—nonbenzodiazepine anti- 6. 15% of depressed individuals attempt suicide anxiety agent 7. Risk factors for suicide include: (a) Drug effect—partial agonism or a. Prior attempt/family history of suicide mixed agonism/antagonism at attempt

5-HT1A receptors b. Male gender (b) Side-effects—nausea, dizziness, c. Substance abuse/family history of sub- headache, restlessness stance abuse (c) Drug interactions—hypertensive d. Living alone crisis with MAOIs; Cytochrome e. Medical illness P450 effect f. Hopelessness (d) Contraindications/precautions— g. Psychosis or panic disorder pregnancy category B h. Advanced age b. Panic disorder (1) Benzodiazepines—for rapid relief of • Signs and symptoms disabling symptoms, alprazolam 1. As listed in definition (2) SSRI—paroxetine, fluoxetine, sertra- 2. Vague pain, headaches, GI complaints, sexual line; SNRI—venlafaxine complaints 3. Client education a. Caution about potential for physical/ • Physical findings psychological dependence with use of 1. Poor eye contact, tearful, downcast benzodiazepines 2. Inattention to appearance/hygiene b. Caution against use of alcohol or other 3. Slow, monotone speech CNS depressants with benzodiazepines 4. Psychomotor retardation or agitation c. Discuss the use of relaxation techniques 5. Impaired cognitive reasoning and effective coping mechanisms • Differential diagnosis Depression 1. Adjustment disorder following a stressor event 2. Bereavement or grief reaction • Definition (DSM-IV-TR)—at least five of the symp- 3. Dysthymia toms listed must be present for 2 weeks and #1 a. Depressed mood for 2 years or #2 must be present for a diagnosis of major b. With two of the following—appetite or depression sleep disturbance, fatigue, low self- 1. Sad or depressed mood most of the day, every esteem, poor concentration, hopelessness day 4. Other psychiatric syndromes 2. Loss of interest in usual activities 5. Medical disorders—thyroid disorders, sleep 3. Fatigue, weight gain/loss, sleep disturbance, apnea, Parkinson’s disease, multiple sclerosis difficulty concentrating, feelings of 6. Medications—corticosteroids, antihyperten- worthlessness/guilt, psychomotor sives, benzodiazepines, chemotherapeutic retardation/agitation, suicidal ideation drugs and others Psychosocial Problems 321

• Diagnostic tests/findings inhibitors; uncontrolled narrow-angle 1. Laboratory/diagnostic tests may be done to glaucoma exclude other diagnostic possibilities c. Other classes of antidepressants a. CBC, chemistry profile (1) Mirtazapine—stimulates release of b. TSH norepinephrine and serotonin; side- c. VDRL effects include fatigue, dizziness, tran- 2. Screening tools—depression assessment sient sedation, and weight gain scales (2) Nefazodone—inhibits serotonin a. Ask patients to rate severity or frequency reuptake and weakly inhibits norepi- of various symptoms nephrine reuptake; side-effects in- b. Beck Depression Inventory, Zung Self- clude drowsiness, dry mouth, nausea, Rating Depression Scale, Geriatric Depres- dizziness, risk of hepatotoxicity; little sion Scale or no sexual dysfunction (3) Bupropion—decreases reuptake of • Management/Treatment dopamine in the CNS; major side- 1. Nonpharmacologic—psychotherapy, electro- effects include agitation, headache, convulsive therapy; hospitalization may be and nausea; no sexual side-effects required for severe depression or if client has d. Once full remission achieved, continue suicidal ideation therapy for 6 to 12 months; for second 2. Pharmacologic episode continue therapy for 1 to 2 a. Selective serotonin reuptake inhibitors years; a third episode requires indefinite (SSRIs) have replaced tricyclic antide- maintenance pressants (TCAs) as the drugs of choice 3. Client education because of their improved tolerability and a. SSRIs—usually taken in morning to reduce safety if taken in overdose incidence of insomnia (1) Agents—fluoxetine, sertraline, parox- b. Antidepressants should be started slowly etine, citalopram, escitalopram and dose increased to a therapeutic level (2) Drug action—block reuptake of that alleviates symptoms serotonin enhancing serotonin c. An adequate trial period and close follow- neurotransmission up are essential for successful treatment (3) Side-effects—anxiety, insomnia/ d. Caution concerning use of medications hypersomnia, headache, nausea, an- with alcohol orexia, sexual dysfunction e. Encourage use of support systems, effec- (4) Drug interactions—use with MAO tive coping mechanisms inhibitors may cause hypertensive crisis; CYP450 drug-drug interactions • Referral (5) Contraindications/precautions— 1. Patients requiring referral to a psychiatrist not to be used in conjunction with include those with suicidal ideation or severe MAO inhibitors; screen patients for depression; bipolar disorder; atypical depres- symptoms of bipolar disorder before sion, substance abuse, treatment resistance prescribing to avoid precipitating a 2. Referral to a licensed counselor should be of- manic episode; pregnancy category C; fered to most patients with depression caution in nursing mothers b. Selective serotonin and norepinephrine Domestic Violence/Intimate Partner reuptake inhibitors (SNRIs) Violence (1) Agents—venlafaxine, duloxetine (2) Drug action—inhibits both serotonin • Definition—a pattern of coercive and controlling and norepinephrine reuptake behavior that occurs in an intimate adult relation- (3) Side-effects—nausea, dizziness, in- ship; includes both psychological and physical somnia, somnolence, dry mouth, abuse constipation (4) Drug interactions—MAO inhibitors, • Etiology/Incidence tryptophan, other SSRIs or SNRIs, 1. 1 in 10 women is battered annually by the man CYP1A2 inhibitors, other with whom she lives (5) Contraindications/precautions—not 2. Battering is a causative factor in 25% of female to be used in conjunction with MAO suicide attempts and 4000 homicides each year 322 Chapter 8 Nongynecological Disorders/Problems

3. Battering is the single most common reason c. Confidential—assure the woman that the women go to emergency rooms information she shares is confidential 4. 12% of teenagers and more than 20% of college d. Document—record any findings that may students have experienced dating violence be helpful to the woman at a later date; 5. Pregnant women may be at increased risk for use accurate description of incident and/ initiation or escalation of abuse or threats in patient’s own words; include all pertinent physical examination find- • Signs and symptoms ings with body map and/or photographs 1. History of frequent visits to emergency room with woman’s permission 2. Evidence of current or old injuries e. Educate—provide information about 3. Delay in reporting an injury/explanation of available resources, dangers of escalating cause inconsistent with injury violence, and safety plans 4. Depression, anxiety, posttraumatic stress reac- 5. Referrals tions, low self-esteem a. Shelters 5. History of suicide attempts or ideation b. Legal assistance 6. Alcohol or drug abuse c. Counseling 7. Vague or nonspecific physical complaints 6. Mandatory reporting—laws vary in each state 8. Late/sporadic prenatal care or other health care Sexual Assault/Abuse 9. Controlling partner/increased anxiety in presence of partner • Definition 10. Behavioral problems in children who are wit- 1. Sexual assault—force, threats, or coercion to nessing the abuse engage in any unwanted sexual contact; in- 11. Cycle of violence—tension building, serious cludes contact or penetration of the intimate battering incident, honeymoon phase parts (sexual organs, anus, groin, buttocks, and breasts) • Physical findings 2. Sexual abuse—repeated sexual assault within a 1. Facial lacerations relationship 2. Injuries to breasts, back, abdomen, and 3. Rape—sexual assault that involves penetra- genitalia tion, however slight, of the labia by the penis; 3. Bilateral injuries to arms/legs legal definitions of rape vary from state to state 4. Obvious patterns—bite marks, hand grip, ciga- but typically include the use of force, threat, or rette burns coercion and lack of consent by the victim in 5. Injuries during pregnancy relation to sexual intercourse 6. Recurrent or chronic injuries • Etiology/Incidence • Differential diagnosis 1. Sexual assault occurs in all age, race, ethnic, 1. Accidental injuries and cultural groups 2. Self-inflicted injuries 2. The majority of rapes are perpetrated by an ac- quaintance of the victim rather than a stranger • Diagnostic tests/findings—none • Signs and symptoms • Management/Treatment 1. Genital injury may or may not be present and 1. Routine assessment for abuse in all women is often difficult to visualize 2. Danger assessment—suicide or homicide 2. Typical findings include lacerations, ecchymo- 3. Safety plan—where to go in an emergency or sis, abrasions, erythema, and edema in areas dangerous situation; what to do during vio- of assault lent incidents; what items/documents will be 3. Rape trauma syndrome describes the symp- needed for a comfortable and safe escape toms that occur in most victims of sexual 4. ABCDEs of intervention assault a. Alone—assure the woman that she is a. Acute phase—lasts a few days to a few not alone in being a victim of domestic weeks violence (1) Emotional responses may be ex- b. Belief—let the woman know that you be- pressed or controlled ranging from lieve that no one deserves to be hurt or anger, fear, anxiety, and restlessness to threatened in a relationship a calm, composed, subdued affect Psychosocial Problems 323

(2) Physical responses include general 5. Prophylactic treatment for STDs and emer- soreness and soreness in the areas of gency contraception if indicated assault; gastrointestinal and genito- 6. Referrals urinary symptoms; sleep disruption a. Healthcare provider for follow-up STD and and nightmares; and sexual disruption HIV testing b. Reorganization phase—wide range of b. Legal and social service referrals emotions and physical responses with c. Counseling for victim and family the purpose of reorganizing life after the assault Eating Disorders 4. Posttraumatic stress disorder occurs when rape trauma syndrome extends beyond 1 • Definitions month and when the victim exhibits the fol- 1. Anorexia nervosa—DSM IV criteria for diagno- lowing behavioral criteria: sis include: a. Persistent reexperiencing of the event a. Refusal to maintain body weight at or (nightmares, flashbacks) above a minimal normal weight for age b. Avoidance of certain activities, places, and and height people that arouse recollections of the b. Intense fear of gaining weight even though event underweight c. Increased arousal (sleep difficulties, c. Disturbed body image difficulty concentrating, irritability, d. Amenorrhea or the absence of at least hypervigilance) three consecutive menstrual cycles when d. Clinically significant distress or impair- otherwise expected ment in social, occupational, or other im- 2. Bulimia nervosa—DSM IV criteria for diagno- portant areas of functioning sis include: a. Recurrent episodes of binge eating • Physical findings b. Recurrent, inappropriate compensatory 1. Physical findings may be minimal or not ap- behavior to prevent weight gain (self- parent until a day or more after the assault induced vomiting; misuse of laxatives, di- 2. Lacerations, ecchymosis, abrasions, erythema, uretics or enemas; strict dieting or fasting; edema in areas of assault excessive exercise) 3. Colposcopic examination may be used to as- c. Binge eating and inappropriate compen- sist in evaluation satory behaviors occur on the average at least twice a week for at least 3 months • Differential diagnosis d. Persistent over-concern with body shape 1. Accidental injuries and weight 2. Domestic violence—nonsexual • Etiology/Incidence • Diagnostic tests/findings 1. Anorexia nervosa 1. Forensic evidence collection technique and re- a. Etiology—biologic, psychological, social, quirements may vary from state to state—most and family factors states supply evidence collection kits that con- b. About 1% of female adolescents have tain instructions and collection materials anorexia 2. STD tests, HIV testing, and pregnancy testing c. Age of onset—early to late adolescence should be offered d. 10% mortality due to starvation, electrolyte imbalance, or suicide • Management/Treatment e. Risk factors include: 1. Comprehensive care for sexual assault vic- (1) Female gender tim is often provided by a multidisciplinary (2) Parent or sibling with eating disorder team that includes a sexual assault nurse (3) Career choice or aspiration that examiner (SANE), victims’ advocate, and law stresses thinness, perfection, or self- enforcement discipline 2. Triage and immediate treatment of any life- (4) A difficult transition or loss (leaving threatening injuries home for college, breakup of an im- 3. Attention to emotional needs of the victim portant relationship) 4. Collection of evidence per state and agency 2. Bulimia nervosa protocol a. Etiology—biologic, psychological, social, and family factors 324 Chapter 8 Nongynecological Disorders/Problems

b. Age of onset—late adolescence to early a. Weight is less than or equal to 70% of ideal adulthood body weight c. Occurs in 4% of college age women b. Client is suicidal d. Mortality rate lower than with anorexia c. Client fails outpatient treatment nervosa 4. Pregnancy considerations—individuals with e. 30–80% of bulimics have history of an- anorexia nervosa may have fertility problems; orexia nervosa pregnant individuals with eating disorders will require special nutritional management to as- • Signs and symptoms sure adequate weight gain and nutrient intake 1. Anorexia nervosa—fatigue, cold intolerance, muscle weakness and cramps, dizziness, Addictive Disorders (Alcohol and Drugs) fainting spells, bloating, amenorrhea, social isolation, excessive concerns about weight, • Definitions compulsive exercising, odd food rituals, 1. Substance dependence (DSM IV criteria)— depression maladaptive pattern of substance use leading 2. Bulimia nervosa—menstrual irregularities, de- to significant impairment or distress with at pression, anxiety, impulsive behaviors (shop- least three of the following occurring within a lifting, alcohol or drug abuse, unsafe sexual 12-month period: behaviors), lack of meaningful relationships, a. Tolerance excessive concerns about weight, requests for b. Withdrawal syndrome or use of substance diet pills, diuretics, or laxatives to relieve withdrawal symptoms c. Substance taken in larger amounts or over • Physical findings a longer period of time than intended 1. Anorexia nervosa—emaciation, dry skin, fine d. Persistent desire or unsuccessful attempts body hair (lanugo), muscle wasting, periph- to cut down use eral edema, bradycardia, arrhythmias, hy- e. Significant amount of time spent ob- potension, delayed sexual maturation, stress taining, consuming, or recovering from fractures substance 2. Bulimia—erosion of tooth enamel, calluses on f. Important social or occupational activities dorsal surface of hands from inducing vomit- reduced because of substance use ing, swollen parotid glands, cardiac arrhyth- g. Persistent use despite knowledge of so- mias if syrup of ipecac used cial, psychological, or physical problems caused by its use • Differential diagnosis 2. Substance abuse (DSM IV criteria)—maladap- 1. Gastrointestinal disorders tive pattern of use leading to a significant 2. Malignancies impairment or distress with at least one of the 3. Depression following within a 12-month period: 4. Psychiatric disorders a. Recurrent substance use resulting in a failure to fulfill major role obligations (work, • Diagnostic tests/findings school, home) 1. Anorexia—mild anemia, elevated BUN, cho- b. Recurrent use in situations where use lesterol, and liver function tests, electrolyte is physically hazardous (driving while imbalance, low serum estrogen, abnormal intoxicated) ECG c. Recurrent substance abuse-related legal 2. Bulimia—electrolyte imbalance, abnormal problems ECG d. Continued use despite knowledge of having a persistent or recurring social or • Management/Treatment interpersonal problem that is caused or 1. Outpatient treatment—individual/group/ worsened by the substance use family therapy, nutritional counseling, treat- e. Symptoms have never met the criteria for ment of any medical complications, treatment substance dependence of any associated mood disorders 2. Pharmacologic—SSRI fluoxetine approved for • Etiology/Incidence treatment of bulimia 1. Genetic, cultural, biochemical, behavioral, and 3. Hospitalization is indicated if any of the fol- psychological factors have all been considered lowing apply: in the etiology of substance dependence Questions 325

2. 6% of adult women have serious problems • Differential diagnosis with alcohol 1. Psychiatric disorders that could account for 3. Approximately one third of alcoholics in the the signs and symptoms, e.g., depression, US are women anxiety disorders, schizophrenia 4. Other drugs of abuse include opioids, de- 2. Medical conditions that could account for the pressants, stimulants, hallucinogens, and signs and symptoms, e.g., endocrinopathies, marijuana seizure disorders, head injury 5. Substance abuse is involved in over 50% of domestic violence and in 50% of driving accident • Diagnostic tests/findings fatalities 1. Blood alcohol level may be elevated 2. Elevated gamma glutamyl transferase (GGT) • Signs and symptoms indicates heavy or chronic alcohol use 1. Alcoholism 3. Urine toxicology tests for other drugs of abuse a. Frequent falls/minor injuries, blackouts, 4. Consider other laboratory and diagnostic tests legal or marital problems, depression, based on risk factors and clinical presentation vague GI complaints, sleep disorders, withdrawal symptoms, seizures • Management/Treatment b. The National Institute on Alcohol Abuse 1. Follow federal and state laws regarding protec- and Alcoholism (NIAAA) recommends tion of confidentiality for persons receiving asking all clients if they ever drink alcohol, alcohol and drug abuse treatment services and if the answer is yes, ask about maxi- and treatment of minors for alcohol and drug mum number of drinks on any occasion abuse without parental consent in past month, how many drinks they have 2. Detoxification—outpatient or inpatient on a typical day when they drink, and how 3. Addiction counseling many days per week they drink to identify 4. Prevention of relapse hazardous drinkers a. Alcoholics Anonymous, Narcotics c. CAGE is one of several screening tools Anonymous used to assess a drinking problem b. Pharmacologic agents—short-term ad- (1) Have you ever felt you should cut juncts to psychosocial treatment down on your drinking? (1) Naltrexone—alcohol craving is re- (2) Have people annoyed you by criticiz- duced in about one-half of patients ing your drinking? (2) Disulfiram—creates a toxic response (3) Have you ever felt bad or guilty about when patient consumes alcohol your drinking? c. Family involvement—counseling, Al- (4) Have you ever had a drink first thing Anon, Ala-Teen, Nar-Anon in the morning to steady your nerves d. Employee assistance programs or get rid of a hangover (eye-opener)? 2. Signs and symptoms of depressant (benzodi- Â Questions azepine, barbiturate) abuse—euphoria, apathy, violent, or bizarre behavior Select the best answer. 3. Signs and symptoms of stimulant (cocaine, amphetamine) abuse—anxiety, euphoria, 1. A systolic heart murmur present in an asymp- violent or bizarre behavior, hallucinations, tomatic pregnant woman is likely: nausea/vomiting a. Due to valvular disease b. Associated with history of rheumatic fever • Physical findings c. A physiologic (innocent) murmur 1. Alcoholism—hepatomegaly, tremors, periph- d. To intensify with Valsalva maneuver eral neuropathy, ataxia, confusion, impairment of recent memory 2. Which of the following if left untreated may 2. Depressants—psychomotor retardation, progress to squamous cell carcinoma? slurred speech, lack of coordination, tremors a. Keratosis pilaris 3. Stimulants—diaphoresis, hypertension, b. Seborrheic keratosis tachycardia, hyperactive deep tendon reflexes c. Actinic keratosis (DTR), pupil dilation, tremors, seizures d. Lichen planus 326 Chapter 8 Nongynecological Disorders/Problems

3. Which of the following is not a finding in 10. Important nonpharmacologic treatments for asthma? acute low back pain do not include: a. Shortened expiratory phase a. Continuation of daily activities b. Wheezing b. Heat application c. Tachypnea, dyspnea c. Strength-building exercises d. Diminished lung sounds d. Bedrest 4. Which of the following is consistent with a 11. Osteoarthritis may be distinguished from rheu- diagnosis of mild persistent asthma? matoid arthritis by: a. Symptoms fewer than twice a week a. The severity of pain reported b. Daily symptoms b. Asymmetry of involvement c. Symptoms 3–6 days of the week c. The joints involved d. Nocturnal symptoms less than twice per d. Length of time symptoms have been in month evidence 5. Approximately what percent of tuberculosis 12. “RICE” therapy refers to: infections will cause active disease? a. A nonpharmacologic therapy plan for a. 75% muscle injuries b. 60% b. A bland diet therapy for nausea and c. 30% vomiting d. 10% c. A weight loss plan d. A combination therapy for peptic ulcer 6. Which of the following is considered a positive disease PPD reaction? 13. A 46-year-old female presents with complaints a. A healthy individual with a tuberculin reac- of worsening low back pain after lifting a heavy tion of 5 mm object the previous day. History of intermittent b. A 55-year-old with active liver disease and a low back pain in the last year, but notes the tuberculin reaction of 5 mm pain is now radiating down her right leg. No c. A low-risk female who is 28 years old with a complaints of trouble with urination or bowel tuberculin reaction of 10 mm movements. On exam, there is decreased range d. An HIV-infected female with a tuberculin of motion of the spine in all planes. Straight leg reaction of 5 mm raising at 35° is positive on the right. Achilles 7. Which of the following is not an anticipated tendon reflex on the right is diminished com- symptom of active TB infection? pared to the left with decreased sensation over the right lateral foot. The most likely etiology a. Tachycardia of this patient’s symptoms is: b. Chest pain c. Weight loss a. Rupture of the achilles tendon d. Night sweats b. Cauda equina syndrome c. Herniated disc involving L5 root 8. Which cohort is most frequently affected by d. Herniated disc involving the S1 root migraine headache? 14. A 27-year-old female presents with moderate a. Teenagers sore throat, runny nose, cough, and general b. Males and females equally malaise for the past 2 days. Physical exami- c. Females nation reveals temperature of 99.8°F, mild d. Postmenopausal women pharyngeal erythema, and no exudates. Appro- 9. Referral for neurologic evaluation of headaches priate management includes: is indicated when: a. CBC with differential a. New headaches occur in an individual older b. Rapid strep antigen test than 50. c. Saline gargles b. There is a family history of stroke. d. Antibiotic treatment c. Focal neurologic deficits precede headache 15. Risk of vertical transmission of the HIV virus has episodes. been reduced by: d. New “triggers” are identified in migraine pattern. Questions 327

a. Artificial rupture of membranes at 38 21. Diagnosis of SLE is made by: weeks a. Abnormal antinuclear antibodies (ANA) b. Antiretroviral treatment of infants titer c. Stopping maternal therapy in pregnancy in b. Presence of at least four combined signs, order to reduce CD4+ counts symptoms, and laboratory findings d. Antiretroviral therapy during pregnancy c. Presence of a specific hematologic disorder 16. The confirmatory test for HIV infection is: on a single occasion d. Identification of an immunologic disorder a. Enzyme-linked immunosorbent assay such as abnormal anti-DNA (ELISA) b. Quantitative plasma HIV RNA 22. Systemic lupus erythematosus is usually charac- c. CD4+ lymphocyte count terized by: d. Western blot a. Periods of exacerbation and remission 17. An important principle of antiretroviral therapy b. Slow, steady disease progression is: c. Initial symptoms of typical skin eruptions d. Remission in pregnancy a. Response to drug therapy is monitored with CD4+ counts. 23. Which of the following is not suspect in the eti- b. Monotherapy is recommended. ology of rheumatoid arthritis? c. Response to drug therapy is monitored by a. Genetic factors HIV RNA levels. b. Environmental factors d. Therapy should be started when symptoms c. Hormonal factors first appear. d. Joint trauma A 34-year-old female presents with a 2-month 24. The World Health Organization standard for history of a nonproductive cough associated anemia diagnosis in women is: with shortness of breath. She complains of fatigue and has noted an intermittent fever for a. Hemoglobin < 10 g/dL the past 6 weeks. Significant cervical, inguinal, b. Hemoglobin < 11 g/dL and axillary lymphadenopathy is noted. Her c. Hemoglobin < 12 g/dL HIV test is positive. Chest x-ray shows a bilateral d. Hemoglobin < 13 g/dL infiltrate, and she is diagnosed with pneumo- 25. Otitis media is suspected when deep ear pain cystis pneumonia (PCP). Questions 18 and 19 develops concurrent with or following: refer to this case. a. An allergic reaction 18. HIV infection produces a spectrum of disease. b. An asthma attack This patient’s symptoms place her in which c. An upper respiratory infection stage of HIV infection? d. Persistent headache a. Acute HIV infection 26. Treatment of bacterial conjunctivitis will often: b. Asymptomatic infection a. Show dramatic results within 48 hours c. Early symptomatic infection b. Take 3 to 5 days before improvement is d. AIDS apparent 19. INH prophylaxis would be recommended for c. Work best with concomitant use of this patient if her PPD was: vasoconstrictors d. Cause drainage to appear within 24 hours a. ≥ 5 mm b. ≥ 10 mm 27. A 26-year-old female patient presents with her c. ≥ 15 mm first episode of acute bacterial sinusitis. She d. ≥ 20 mm is allergic to penicillin. The most appropriate management would be: 20. Risk factors for systemic lupus erythematosus (SLE) include all but which of the following? a. Sulfamethoxazole/Trimethoprim b. Levofloxacin (Levaquin) a. Female gender c. Amoxicillin b. Reproductive age group d. Fluticasone Nasal Spray c. First-degree relative with SLE d. Caucasian race 328 Chapter 8 Nongynecological Disorders/Problems

28. A 21-year-old female presents with symp- c. Diarrhea as the initial symptom toms suggestive of infectious mononucleosis. d. Pain in periumbilical area followed by local- Which of the following does not support the ization to the RLQ diagnosis? 35. Peptic ulcer disease associated with presence of a. Pharyngitis H. pylori can be diagnosed by: b. Positive monospot/heterophile antibody a. Visualization of H. pylori on Gram stained test preparation c. CBC with atypical lymphocytes b. Negative urea breath analysis d. Cough c. Negative urease assay via endoscopy 29. The group most often affected by infectious d. Serology positive for H. pylori antibodies mononucleosis is: 36. Initial laboratory evaluation of a patient pre- a. Prepubertal children senting with symptoms suggestive of acute viral b. Women of reproductive age hepatitis should include: c. Females at any age a. IgG anti-HAV d. Teens to early twenties b. HBsAg and IgM anti-HBc 30. The most common reason for painless rectal c. IgM anti-HAV bleeding with defecation is: d. HBsAg, IgM anti-HBc, and IgM anti-HAV a. External hemorrhoids 37. The primary goal of pharmacologic therapy for b. Internal hemorrhoids acute viral hepatitis B is: c. Rectal polyps a. Prevention of secondary infection d. Colorectal cancer b. Relief of symptoms A 21-year-old female complains of intermittent, c. Reduction of infectivity loose stools with pain and flatulence. After d. Prevention of complications defecation, there is a temporary feeling of 38. Most gallstones are composed of: relief. Symptoms increase during times of stress. Patient denies weight loss, fever, or blood in a. Precipitated bile salts the stool. Questions 31 and 32 refer to this case. b. Precipitated calcium salts c. Cholesterol 31. Which of the following is the most likely d. Pigments diagnosis? 39. A 45-year-old female presents with right-upper a. Ulcerative colitis quadrant (RUQ) pain that radiates to the right b. Irritable bowel syndrome infrascapular area. The pain is described as c. Lactose intolerance colicky and was precipitated by eating pizza. d. Intestinal parasitic infection Onset of the symptom was a few hours ago and the pain is beginning to ease. There was associ- 32. A recommended dietary change for Linda’s epi- ated nausea and vomiting. The initial study of sodes of diarrhea includes: choice in this patient is: a. Decrease caffeine, gas forming foods a. Plain abdominal radiograph b. Low-fiber diet b. Ultrasound c. Eliminate all dairy products c. Computerized tomography (CT) d. Vitamin supplements d. Percutaneous transhepatic cholangiogram 33. African-American women are at increased risk 40. Among the following causes of viral hepatitis, for: which of the following is most likely to lead a. Systemic lupus erythematosus to chronic infection and is the most common b. Skin cancer reason for liver transplantation? c. Iron deficiency anemia a. Hepatitis A d. Tinea b. Hepatitis B 34. Appendicitis typically presents with which of c. Hepatitis C the following? d. Hepatitis D a. High fever as the initial symptom 41. Patients with acute cholecystitis should be b. Pain beginning in the right-lower quadrant advised: (RLQ) Questions 329

a. To undertake strict weight reduction diets c. A 3-hour glucose tolerance test on a subse- if obese quent day

b. Of the likelihood of recurrence d. A HbA1c c. That immediate surgery is a recommended 47. Which of the following is most indicative of treatment poor control in a patient with type 2 diabetes? d. Of the availability of lithotripsy as a highly successful treatment a. Average preprandial plasma glucose of 118 mg/dL A 35-year-old overweight female presents with b. Average peak postprandial glucose of 145 intermittent heartburn for several months. The mg/dL use of Tums provides temporary relief. During c. Average random glucose of 175 mg/dL the past week, she has been awakened during d. HbA of 8.5% the night with a burning sensation in her chest. 1c She is not taking any other medications and 48. The condition comprising 90% of hyperthy- has no major health problems. Questions 42–44 roidism is: refer to this case. a. Graves’ disease b. Thyroiditis 42. What additional information would support a c. Toxic goiter diagnosis of gastroesophageal reflux disease d. Adenoma (GERD) as the cause of her symptoms? 49. Infiltrative ophthalmopathy (exophthalmos) is a. She has occasional nausea and vomiting. unique to which of the following disorders? b. She often notes coughing during the night and a bad taste in her mouth. a. Graves’ disease c. The pain is usually relieved by eating. b. Hashimoto’s thyroiditis d. Constipation has been a chronic problem c. Toxic multinodular goiter and she uses laxatives twice a week. d. Papillary thyroid carcinoma 43. Your patient denies weight loss, dysphagia and 50. Which of the following test results would be dark, tarry stools. What is your next step? expected with primary hyperthyroidism?

a. Order an endoscopic exam a. Low serum TSH and elevated free T4

b. Start her on H2 receptor blockers b. Low serum TSH and low free T4

c. Tell her to eat a snack before bedtime c. High serum TSH and elevated free T4

d. Refer her to a gastroenterologist d. High serum TSH and low free T4 44. Assuming a diagnosis of GERD, you would 51. A patient with a history of radioactive iodine advise that: treatment for Graves’ disease presents with fatigue, weight gain, and dry skin. You would a. She probably has a hiatal hernia causing expect this patient to have which of the fol- the reflux. lowing laboratory findings? b. She will likely require surgery.

c. She should avoid all fruit juices. a. Low T3, low TSH, high total T4

d. Smoking, alcohol, and caffeine will likely b. Low TSH, high total T4, normal free T4

aggravate the problem. c. High TSH, low free T4 d. High TSH, high free T 45. The laboratory diagnosis of diabetes mellitus 4 can be determined by: 52. A 35-year-old female was diagnosed with Hashimoto thyroiditis and placed on 0.1 mg of a. Fasting plasma glucose ≥ 126 mg/dL levothyroxine. After 1 week of treatment, the b. A 2-hour postprandial glucose ≥ 126 mg/dL patient states that she still feels fatigued. How c. HbA > 7% 1c would you manage this patient? d. Random glucose ≥ 150 mg/dL a. Increase the dose of levothyroxine to 0.125 46. A 60-year-old female presents for a physical mg exam. She has no complaints. Fasting blood b. Schedule an appointment this week to have sugar is 188. You suspect diabetes. To confirm a TSH drawn the diagnosis, you would order: c. Add propranolol to the regimen a. No further testing is necessary d. No change in levothyroxine is indicated at b. A fasting blood sugar on a subsequent day this time 330 Chapter 8 Nongynecological Disorders/Problems

53. A factor not associated with exacerbations of 60. A 20-year-old female presents with two annular facial acne is: lesions with a scaly border and central clearing on her trunk. The lesions have been present for a. Hormonal cycling 1 week and are mildly pruritic. What is the most b. Stress likely diagnosis? c. Fried foods d. Hot humid environments a. Psoriasis b. Pityriasis rosea 54. The most important point to stress with female c. Tinea versicolor patients using isotretinoin for acne is: d. Tinea corporis a. Possibility of hematologic disturbances 61. A 20-year-old female presents with com- b. Rare occurrence of pseudotumor cerebri plaint of itching, red eye with a sticky, yellow c. Necessity for highly effective contraception discharge that started in one eye yesterday d. Avoiding alcohol while on this drug afternoon and this morning is in both eyes. She 55. An 18-year-old presents with open and closed states no fever or other symptoms. The most comedones and a few scattered papules. The likely diagnosis is: most appropriate first line treatment would be: a. Allergic conjunctivitis a. Topical antibiotics b. Bacterial conjunctivitis b. Oral tetracycline c. Bacterial blepharitis c. Tretinoin cream (Retin-A) d. Viral conjunctivitis d. Isotretinoin (Accutane) 62. The most common reason for lumbosacral back 56. The most common form of skin cancer is: pain is: a. Squamous cell a. Herniated disc b. Basal cell b. Muscle strain c. Malignant melanoma c. Neoplasm d. Basal cell nevus syndrome d. Arthritis 57. A 60-year-old presents with a pearly, trans- 63. A 28-year-old female presents with complaints lucent smooth papule with rolled edges and of low back pain after helping a friend move 2 surface telangiectasias on her forehead. She days ago. She denies any radiation of the pain, notes that it has been there for at least a year, numbness, or tingling in the lower extremi- but has recently increased in size. The lesion ties or problems with elimination. On physical most likely represents which of the following? exam, mild paravertebral muscle spasm is noted with decreased range of motion of the spine. a. Squamous cell carcinoma No focal neurologic findings. Appropriate man- b. Basal cell carcinoma agement would include: c. Seborrheic keratosis d. Malignant melanoma a. Radiograph of the lumbosacral spine b. Bedrest for 3–4 days 58. Education for the woman with systemic lupus c. NSAIDs erythematosus (SLE) should include which of d. Referral to neurologist the following? 64. The frequency of sickle cell crises may be a. She should not use hormonal reduced by: contraception. b. She should receive annual live attenuated a. Activity restrictions influenza vaccine. b. Oxygen therapy c. If she becomes pregnant, a C-section will be c. Aggressive treatment of infections planned to avoid stress of labor. d. High protein diet d. She should use sunscreen and protective 65. Which of the following is an expected finding clothing when outdoors. in tinea unguium? 59. Which of the following is not a risk factor for a. Hair loss in affected areas malignant melanoma? b. Negative KOH slide preparation a. Hispanic ethnicity c. Yellowish, thickened nails b. Multiple pigmented nevi d. Crusted ulcerations c. Severe childhood sunburn d. Family history Questions 331

66. About 10% of those infected with hepatitis B 72. Which of the following most likely suggests a virus become chronic carriers of the disease, a secondary cause of hypertension? state putting them at risk for: a. BMI greater than 30 a. Hepatocellular carcinoma b. Abdominal bruit b. Mononucleosis c. Total cholesterol greater than 280 c. Gall bladder disease d. Enlarged spleen d. Chronic immunocompromised status 73. Before a diagnosis of hypertension can be 67. Your patient’s blood work returns with a posi- made, follow-up must include: tive hepatitis B surface antigen (HBsAg). This a. Minimum of one more visit with BP suggests: > 140/90 mm Hg a. Chronic liver disease b. Serum creatinine and potassium levels b. Previous infection with hepatitis B virus c. Evaluation for possible hyperlipidemia and c. Acute or chronic infection with hepatitis B diabetes virus d. 12-lead electrocardiogram d. Recent vaccination 74. A 21-year-old college student is brought to the 68. The incidence of upper respiratory infection: clinic because she fainted in class. She states she has been having daily dizzy spells. Physical a. Is enhanced by cold, damp weather examination reveals an underweight female b. Peaks in winter months with heart rate of 58 beats per minute and c. Peaks in spring/summer allergy season blood pressure 96/52 mm Hg. Of the following d. Doesn’t vary much season to season conditions, this client’s symptoms and examina- 69. Management of constipation should include: tion findings are most indicative of: a. Routine use of stool softeners a. Agorophobia b. Bulk-forming agents in the management of b. Anorexia nervosa acute constipation c. Cocaine abuse c. Hyperosmolar laxatives (sorbitol) as d. Depression the initial drug of choice for chronic 75. Which of the following is not classified as constipation thromboembolic disease? d. Saline laxatives (milk of magnesia) in the management of acute constipation a. Deep vein thrombosis b. Pulmonary embolus 70. Which of the following patients with sinusitis c. Superficial thrombophlebitis should be treated with antibiotics? d. Chronic venous insufficiency a. Patient who had onset of sinusitis a few 76. The best initial test to rule out DVT is: days after onset of URI symptoms b. Patient who has postnasal drip, swollen a. Plasma D-dimer pale nasal mucosa, and low-grade fever b. Ascending venography c. Patient who was noting improvement c. Antithrombin III measurement in symptoms, and 5 days later symptoms d. Duplex ultrasound worsen 77. Which of the following is not a recom- d. Patient who has rebound congestion after mended nonpharmacologic treatment for discontinuing several days’ use of decon- thrombophlebitis? gestant nasal spray a. Local heat application 71. A blood pressure of 150/90 mm Hg during b. Passive range of motion exercise a routine examination of an asymptomatic, c. Elevation of affected limb 45-year-old African-American female would d. Compression with an ace wrap indicate: 78. The National Cholesterol Education Program a. Essential hypertension recommends hyperlipidemia screening every b. Probability of underlying disease _____ years beginning at age 20. c. Necessity for follow-up and further evaluation a. 5 d. Normal response to anxiety b. 3 c. 2 d. 1 332 Chapter 8 Nongynecological Disorders/Problems

79. A 44-year-old female presents with obesity, a. Cough type 2 diabetes, and hyperlipidemia. Which of b. Chest pain the following should be your treatment goal? c. Shortness of breath on exertion d. Hemoptysis a. LDL cholesterol < 160 mg/dL b. LDL cholesterol < 130 mg/dL 87. Management for irritable bowel syndrome c. LDL cholesterol < 100 mg/dL (IBS): d. Total cholesterol < 200 mg/dL a. Should not include changes in diet except 80. In patients with established cardiovascular for eliminating milk products disease, the goal for LDL cholesterol is: b. Includes use of medications to reduce incidence of ulcerative colitis a. < 100 mg/dL c. Is based on the predominant symptoms b. < 130 mg/dL experienced by the patient c. < 160 mg/dL d. Includes regular screening for colon cancer d. < 190 mg/dL because of increased risk with IBS 81. A microcytic anemia with a low serum ferritin is 88. Virchow’s triad defines the clinical origin of likely secondary to: most venous thrombi and includes all of the fol- a. Anemia of chronic disease lowing factors except: b. Iron deficiency a. Stasis c. Hyperspleenism b. Endothelial damage d. Thalassemia minor c. Deposition of cholesterol plaques 82. The use of “statins” for pharmacologic therapy d. Hypercoagulability of hyperlipidemia is: 89. A patient presents with signs and symptoms a. Category B use in pregnancy suggestive of a superficial phlebitis. Physical b. Category C use in pregnancy findings in this patient would include: c. Category D use in pregnancy a. Tenderness in the area of the involved vein d. Category X use in pregnancy b. Edema of the involved extremity 83. Of the following signs and symptoms, fibromy- c. Pale, cool skin in the area of involved vein algia most commonly presents with: d. Palpable venous cord a. Abrupt onset of proximal muscle weakness 90. In the United States, the most common cause of b. Widespread musculoskeletal pain and community-acquired bacterial pneumonia is: tender points a. Streptococcus pneumoniae c. Effusion of involved joints with mild local b. Streptococcus pyogenes warmth c. Haemophilus influenzae d. Subcutaneous nodules d. Legionella pneumophilia 84. Secondary causes for high blood cholesterol do 91. A 22-year-old female presents with a complaint not include: of nonbloody diarrhea of 5–6 days dura- a. Diabetes tion. Associated symptoms include abdominal b. Obstructive liver disease cramping, low-grade fever and nausea. She c. Medication-induced states recently returned from a trip to Mexico. Appro- d. Hypothyroidism priate initial evaluation would include: 85. A systolic click preceding a mid-to-late systolic a. Abdominal ultrasound murmur is most likely caused by which of the b. Barium enema following? c. H. pylori testing d. Stool for fecal leukocytes a. Aortic stenosis b. Mitral valve prolapse 92. In rheumatoid arthritis, _____ is/are often c. Mitral valve stenosis found, indicative of the inflammatory process. d. Idiopathic hypertrophic subaortic stenosis a. Fever 86. Which of the following is not a likely symptom b. Elevated erythrocyte sedimentation rate of pathologic murmur? c. Joint erosion on radiography d. Painful joints Questions 333

93. Your patient is experiencing 3–4 migraine 100. Macrocytic anemias include: headaches per month. You decide to begin a. Anemia of chronic disease prophylactic medication. Which of the fol- b. B deficiency anemia lowing is recommended for migraine headache 12 c. Iron deficiency anemia prophylaxis? d. Sickle cell anemia a. Ergotamine 101. A 52-year-old menopausal female client smokes b. Propranolol (Beta blocker) one pack per day and has a history of a deep c. Sumatriptan vein thrombosis in her leg 2 years ago. She has d. SSRI a BMD T-score of –1.75. Which of the following 94. Rheumatoid arthritis is characterized by which medications would be the most appropriate for of the following? this client to prevent osteoporosis? a. Osteophyte formation a. Alendronate b. Cartilage degeneration b. Calcitonin c. Inflammation of the synovium and joint c. Estrogen capsule d. Raloxifene d. Sclerosis of subchondral bone 102. Which of the following statements is correct 95. A 21-year-old college student presents with a concerning bone mass density (BMD) testing? 5-day history of fever, headache, sore throat, a. Test results are most predictive of bone muscle aches, and a nonproductive cough. Her fracture when done on an annual basis. throat is erythematous; lung exam is unre- b. The T-score compares BMD of the client markable. Chest x-ray reveals a left-lower lobe with an age-matched normal adult. patchy infiltrate. The most likely cause is which c. BMD T-scores should be combined with of the following? bone x-ray to confirm osteoporosis. a. Steptococcus pneumoniae d. Treatment decisions based on T-scores may b. Mycoplasma pneumoniae vary according to risk factors. c. Klebsiella pneumoniae 103. A 40-year-old female has complaint of chronic d. Haemophilus influenzae backache and has been diagnosed to have a 96. Acute otitis media is characterized by all of the vertebral compression fracture. She also has hir- following physical examination findings except: sutism, facial acne, and red-purple abdominal striae. An appropriate initial test for a possible a. Distorted light reflex secondary cause for osteoporosis in this client b. Obscured bony landmarks would be: c. Erythema of the ear canal d. Preauricular lymphadenopathy a. Dexamethasone suppression test b. Parathyroid hormone level 97. Laboratory tests supportive of a diagnosis of c. Protein electrophoresis infectious mononucleosis include all of the fol- d. Thyroid function tests lowing except: 104. Client instructions for taking alendronate a. Elevated basophils and eosinophils should include: b. Presence of heterophil antibodies c. Elevated liver enzymes a. Take medication with breakfast d. GABHS on throat culture b. Take medication at bedtime c. Take medication on an empty stomach 98. Secondary causes of seizures include: d. Take medication with an antacid a. Syncope 105. One of the most significant laboratory tests for b. Hyperventilation evaluating an individual for chronic or heavy c. Narcolepsy alcohol use is a/an: d. Toxic substance abuse a. ALP 99. The most common type of seizure disorder in b. BUN adults is: c. CBC a. Clonic-tonic d. GGT b. Partial c. Complex partial d. Grand mal 334 Chapter 8 Nongynecological Disorders/Problems

106. Which of the following is a characteristic 111. A client tells you that she experiences chest finding with stimulant abuse but not depres- tightness, difficulty breathing, and dizziness sant abuse? whenever she has to ride on the city bus. Her symptoms best fit a description of: a. Euphoria b. Pupil dilation a. Acute stress disorder c. Tremors b. Agoraphobia d. Violent behavior c. Obsessive-compulsive disorder d. Social phobia 107. Two months after being raped, a client tells you she cannot concentrate on her schoolwork 112. The most common type of anxiety disorder is: and is having nighmares about the experience. a. Acute stress disorder These symptoms indicate that she: b. Generalized anxiety disorder a. Is still in the acute phase of rape trauma c. Obsessive-compulsive disorder syndrome d. Panic disorder b. Is going through normal reorganization fol- 113. Which of the following statements concerning lowing a rape bulimia is correct? c. Is experiencing posttraumatic stress disorder a. Age of onset is usually early adolescence. d. Now has a generalized anxiety disorder b. Amenorrhea is usually present. c. Mortality rate is higher than for anorexia 108. A client who has been experiencing fatigue, nervosa. insomnia, difficulty concentrating, and feelings d. Impulsive behavior is a common of worthlessness for the past 2 weeks would characteristic. meet the DSM IV criteria for a major depressive disorder if she also has: 114. Major side-effects of SSRIs include: a. Loss of interest in her usual activities a. Anticholinergic effects b. Psychomotor retardation b. Nausea c. Psychosomatic complaints c. Orthostatic hypotension d. Suicidal ideation d. Urinary retention 109. A 22-year-old female presents with three 115. A 35-year-old female with a history of gen- episodes of chest pain, shortness of breath, pal- eralized anxiety disorder requests a refill of pitations, dizziness, sweating, and fear of losing alprazolam. You are concerned about risks control. Onset of symptoms occurred while associated with long-term use. Which of the she was traveling on the bus. She is avoiding following represents an alternative medication? the use of public transportation because she a. Buspirone (Buspar) is fearful of recurrence of the symptoms. The b. Clonazepam (Klonopin) most likely diagnosis is: c. Bupropion (Wellbutrin) a. Panic disorder with agoraphobia d. Citalopram (Celexa) b. Panic attack 116. A behavior that fits the criteria for substance c. Generalized anxiety disorder dependence but not for substance abuse is: d. Social anxiety disorder a. Loss of a job related to substance use 110. A 24-year-old female client with major depres- b. Driving while intoxicated sion tells you that she feels like her life is falling c. Continuing to drink despite family’s apart. She recently lost her job, had to move objections out of her apartment, and now lives with her d. Unsuccessful attempts to cut down use sister. Her risk factors for a suicide attempt include: 117. Physical findings that help the clinician to make a diagnosis of bulimia would include: a. Age between 20 and 30 b. Female gender a. Erosion of tooth enamel c. Current living situation b. Hypotension d. Sense of hopelessness c. Presence of lanugo d. Stress fractures Bibliography 335

118. Which of the following statements concerning 49. a â 85. b rape is correct? 50. a â 86. d a. All of the states have now established the 51. c â 87. c same legal definition for rape. 52. d â 88. c b. The majority of rapes are committed by 53. c â 89. a acquaintances of the victim. 54. c â 90. a c. The most common emotional response of 55. c â 91. d the victim in the acute phase is anger. 56. b â 92. b d. The clinician is responsible for determining 57. b â 93. b if a rape has actually occurred. 58. d â 94. c 119. All of the following symptoms are accepted 59. a â 95. b criteria for a diagnosis of major depression 60. d â 96. c except: 61. b â 97. d a. Feelings of worthlessness or excessive guilt 62. b â 98. d b. Chronic pain without biomedical 63. c â 99. c explanation 64. c 100. b c. Loss of pleasure in usual activities 65. c 101. a d. Psychomotor agitation or retardation 66. a 102. d 120. Severe exacerbations in an individual with 67. c 103. a intermittent (step 1) asthma are appropriately 68. b 104. c treated with: 69. d 105. d 70. c 106. b a. Mast-cell stabilizers 71. c 107. c b. Short acting inhaled B2-agonists c. Systemic corticosteroids 72. b 108. a d. Theophylline 73. a 109. a 74. b 110. d Â Answers 75. d 111. b 76. d 112. b â 1. c â 25. c 77. b 113. d â 2. c â 26. a 78. a 114. b â 3. a â 27. a 79. c 115. a â 4. c â 28. d 80. a 116. d â 5. d â 29. d 81. b 117. a â 6. d â 30. b 82. d 118. b â 7. a â 31. a 83. b 119. b â 8. c â 32. a 84. a 120. c â 9. a â 33. a 10. d â 34. d Â Bibliography 11. b â 35. d Adams, S., Miller, K., & Zylstra, R. (2008). Pharmacologic 12. a â 36. d management of adult depression. American Family 13. d â 37. b Physician, 77(6), 785–796. 14. c â 38. c American Diabetes Association. (2009). Standards 15. d â 39. b of medical care in diabetes—2009. Diabetes Care, 16. d â 40. c 32(Suppl 1), S14–S61. 17. c â 41. c American Psychiatric Association. (1994). Diagnostic 18. d â 42. b and statistical manual of mental disorders (4th ed.). 19. a â 43. b Washington, DC: Author. 20. d â 44. d American Psychiatric Association. (2000). Quick refer- 21. b â 45. a ence to the diagnostic criteria from DSM-IV-TR. Wash- 22. a â 46. b ington DC: Author. Bickley, L. (2009). Bates’ guide to physical examination 23. d â 47. d and history taking (10th ed.). Philadelphia, PA: Lip- 24. c â 48. a pincott, Williams, & Wilkins. 336 Chapter 8 Nongynecological Disorders/Problems

Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. National Heart, Lung, and Blood Institute. (2003). Sev- (2008). Primary care: A collaborative approach (3rd enth report of the Joint National Committee on Pre- ed.). St. Louis: Mosby, Inc. vention, Detection, Evaluation and Treatment of Chakrabarty, S., & Zoorab, R. (2007). Fibromyalgia. High Blood Pressure. (NIH Publication No. 03-5233). American Family Physician, 76, 247–254. Bethesda, MD: Author. Ernst, D., & Lee, A. (Eds.). (Summer 2009). Nurse prac- National Heart, Lung, and Blood Institute. (2001). Third titioner’s prescribing reference. New York: Prescribing report of the National Cholesterol Education Program Reference LLC. Expert Panel on Detection, Evaluation and Treatment Ferri, F. (2009). Ferri’s 2010 clinical advisor. St. Louis: of High Cholesterol in Adults (Adult Treatment Panel Mosby, Inc. III). (NIH Publication No. 01-3095). Bethesda, MD: Fraker, T., & Fihn, S. (2007). 2007 Chronic angina fo- Author. cused update of the ACC/AHA 2002 guidelines for the National Osteoporosis Foundation. (2008). Clinician’s management of patients with chronic stable angina. guide to prevention and treatment of osteoporosis. Circulation, 116, 2762–2772. Washington, DC: Author. Goldman, L., & Ausiello, D. (2007). Cecil’s textbook of Panel on Clinical Practices for the Treatment of HIV. medicine (23rd ed.). Philadelphia, PA: Saunders. (2002). Guidelines for the use of antiretroviral agents Hackely, B., Kriebs, J., & Rousseau, M. (2007). Primary in HIV-infected adults and adolescents. Department care of women: A guide for midwives and women’s of Health and Human Services. Retrieved March 10, health providers. Sudbury, MA: Jones and Bartlett. 2003 from http://www.aidsinfo.nih.gov/guidelines/ Inge, L., & Wilson, J. (2008). Update on the treatment adult/html. of tuberculosis. American Family Physician, 78(4), Williams, P., Goodie, J., & Motsinger, C. (2008). Treating 457–470. eating disorders in primary care. American Family National Heart, Lung, and Blood Institute. (2007). Ex- Physician, 77(2), 187–195. pert panel report 3: Guidelines for the diagnosis and Wynne, A., Woo, T., & Olyaei, A. (2007). Pharmacothera- management of asthma. (NIH Publication No. 08- peutics for nurse practitioner prescribers (2nd ed.). 4051). Bethesda, MD: Author. Philadelphia, PA: F. A. Davis. Advanced Practice 9 Nursing and Midwifery: Role Development, Trends, and Issues

Patricia Burkhardt

¶ ADVANCED PRACTICE REGISTERED providing nursing and medical services to NURSE (APRN) individuals, families, and groups (Ameri- can Academy of Nurse Practitioners, 2007) UÊ ivÌp>ÊÀi}ÃÌiÀi`ÊÕÀÃiÊÜ Ê >ÃÊ>VV- b. Historical development plished the following: (1) 1964—first NP program developed 1. Completed an accredited graduate level pro- at University of Colorado Health Sci- gram preparing him/her for one of four recog- ences Center nized APRN roles (2) Prompted by shortage of area 2. Passed a national certification examination that pediatricians measures APRN role and population compe- (3) Pediatric nurse practitioner (PNP) be- tencies and who maintains certification. Ac- came model for development of NPs quired advanced clinical knowledge and skills in other specialty areas preparing him/her to provide direct care to c. Functions patients, as well as a component of indirect care (1) As a primary care provider (PCP), 3. Is educationally prepared to assume re- provides care that is integrated and sponsibility and accountability for health accessible promotion/maintenance, assessment, di- (2) Emphasizes health promotion, dis- agnosis, and management of patient prob- ease prevention lems, which includes use and prescription (3) Professionally, practice is autono- of pharmacologic and nonpharmacologic mous, collaborative, and evidence interventions based 4. Obtained clinical experience of sufficient (4) Functionally, practice is defined by depth and breadth to reflect the intended state law, regulations, and clinical license. Obtained a license to practice as an privileges APRN in one of the four APRN roles (APRN (5) Diagnoses, treats, and manages health Consensus Workgroup & National Council of problems State Boards of Nursing APRN Advisory Com- (6) Teaches and counsels individuals, mittee, 2008) families, and groups (7) Clinical roles include researcher, con- UÊ / iÊvÕÀÊ*, ÊÀiÃ\ sultant, and patient advocate 1. Nurse practitioners (NPs) (8) Professional roles include mentor, ed- a. Definition—primary and/or specialty ucator, researcher, and administrator care providers who practice in ambula- (9) Maintains accountability for care of tory, acute, and long-term care settings, patients and decisions reached

337 338 Chapter 9 Advanced Practice Nursing and Midwifery: Role Development, Trends, and Issues

d. Education (e) Managing and Negotiating (1) Master’s degree, post-master’s certifi- Healthcare Delivery Systems cate, or Doctorate of Nursing Practice (f) Monitoring and Ensuring the (DNP) Quality of Healthcare Practice (2) Length of study for master’s degree (g) Culturally Sensitive Care approximately 2 years full time; in- e. Certification cludes extensive clinical experience (1) To be eligible to take the certification supervised by qualified preceptors examination offered for the Women’s within a population focus and possi- Health NP, the student must have bly a specialty track graduated from an accredited mas- (3) Current programs for Women’s Health ter’s, post-master’s, or DNP program NP are master’s, post-master’s cer- in the women’s health population tificate, or Doctor of Nursing Practice focus (DNP) (2) Women’s Health Nurse Practitioner (4) Curriculum Certification is provided by the Na- (a) Graduate core courses that in- tional Certification Corporation clude content in nursing theory, (NCC) organizational theory, ethics, (3) Certification must be renewed every research, legal issues, economics, 3 years, through either reexamination healthcare delivery or achievement of specified hours of (b) APRN core content that includes continuing education advanced health assessment, 2. Certified registered nurse anesthetists (CRNAs) physiology/pathology, pharma- (American Association of Nurse Anesthetists, cology, clinical diagnosis and 1999) management, health promotion, a. Definition—an advanced practice nurse and disease prevention and anesthesia specialist who provides (c) Additional courses with content high quality, cost-effective care for pa- specific to the nurse practitioner tients before, during and after surgical role and women’s health popula- procedures in which anesthesia is admin- tion focus; includes extensive su- istered; first clinical nursing specialty; de- pervised clinical hours veloped in late 1800s (d) The National Association of Nurse b. Functions Practitioners in Women’s Health (1) Administers and monitors anesthesia/ (NPWH) and Association of Wom- patient response during surgery en’s Health, Obstetrics and Neo- (2) Acts as clinician, administrator, edu- natal Nurses (AWHONN) (2008) cator, researcher jointly provide guidelines for (3) CRNAs practice more in rural commu- women’s health nurse practitioner nities and provide more than half of practice and education all anesthesia in US (e) Women’s Health NP programs c. Education are accredited within schools of (1) Master’s degree nursing by two organizations: the (2) Programs vary from 24 to 36 months National League for Nursing Ac- and include classroom and clinical crediting Commission (NLNAC) experiences or the Commission on Collegiate (3) National certification is required Nursing Education (CCNE) (4) Must earn continuing education cred- (5) Domains/core competencies of nurse its to maintain certification practitioner practice (National Orga- 3. Clinical nurse specialists (CNSs) nization of Nurse Practitioner Facul- a. Definition—APRN with role of integrating ties, 2006) care across the health–illness continuum (a) Management of Patient Health/ and through three spheres of influence: Illness Status patient, nurse, system (b) Nurse Practitioner–Patient b. Functions Relationship (1) Direct care functions include expert (c) Teaching–Coaching Function practitioner, role model, patient advo- (d) Professional Role cate, and educator Midwifery 339

(2) Indirect care functions include change Midwives signed joint statement supporting agent, consultant or resource person, development of the midwifery role liaison person, and innovator 10. 1980–1990s—full range of practice sites and c. Education services offered by CNMs as profession grew (1) Master’s degree, post-master’s, or DNP 11. 1982—formation of the Midwives Alliance of (2) Curriculum includes core courses in North America (MANA), whose purpose was to nursing theory, organizational theory, provide support and a forum for anyone inter- ethics, legal issues, healthcare de- ested in midwifery livery and CNS role and population 12. Titles used for American midwives focus courses/supervised clinical a. Granny—like traditional birth attendants, experience these women answered to needs of com- 4. Certified nurse-midwife (CNM) or certified munity women; trained by experience and midwife (CM) (see next section) other practicing midwives b. Direct entry midwife—term used to define Â Midwifery two different realities (1) Individual trained in midwifery • History of US Midwifery through apprenticeship method out- 1. Midwifery practice was honored in colonial side the structure of formal education America, but changes in religious attitudes, programs economic demands, development of science, (2) Midwife educated in midwifery with- physician advances, low status of women, and out nursing background lack of organization and education caused the c. Certified Professional Midwife (CPM)— profession to fall into disrepute by the 20th credential developed and administered century by North American Registry of Midwives 2. Need for prenatal education and care identi- (NARM) fied by the Maternity Center Association in d. Certified Nurse Midwife (CNM)/Certified New York City, established 1918; from this the Midwife (CM)—midwife graduated from idea to formally prepare nurses in obstetrics programs accredited by Accreditation arose Commission for Midwifery Education 3. Midwifery education through the Bellevue (ACME)—formerly American College School of Midwifery (1911–1935) in NYC and of Nurse Midwives (ACNM) Division the Preston Retreat Hospital (1923) in Phila- of Accreditation—and certified by the delphia upgraded midwifery education and American Midwifery Certification Board practice (AMCB)—formerly ACNM Certification 4. 1921—passage of the Sheppard-Towner Act to Council (ACC) improve maternal–infant care and provide for e. Licensed midwife (LM)—midwife licensed instruction of untrained midwives through state law; may include any of the 5. 1928—Mary Breckinridge of the Frontier Nurs- previous categories depending on the ing Service (FNS) imported nurse-midwives state’s law from England to serve the people in the Ken- f. Doula—a woman who provides support tucky mountains and assistance to the pregnant woman 6. 1931—the Lobenstein School for the Promo- during birth and/or postpartum tion and Standardization of Midwifery was 13. Midwifery and CNMs/CMs in the 21st century incorporated; was the first formal, organized a. Definition—“Midwifery practice is the midwifery education program independent management of women’s 7. 1955—formation of the American College health care, focusing particularly on preg- of Nurse-Midwifery whose purpose was to nancy, childbirth, the postpartum period, set standards for midwifery practice and care of the newborn, and the family plan- education ning and gynecological needs of women.” 8. 1968—clinical nurse midwifery practice (Varney, Kriebs, Gegor, 2004, p. 3) broadened as Maternal–Infant Care (MIC) in b. Hallmarks of midwifery (Core Competen- NYC linked community clinic practice with cies for Basic Midwifery Practice, 2002) hospital practice (1) Recognition of pregnancy and birth 9. 1971—American College of Obstetricians/ as a normal physiologic and devel- Gynecologists (ACOG), Nurses Association opmental process and advocacy of of ACOG, and American College of Nurse- nonintervention in the absence of complications 340 Chapter 9 Advanced Practice Nursing and Midwifery: Role Development, Trends, and Issues

(2) Recognition of menses and meno- (3) To be eligible to take the certifica- pause as a normal physiologic and tion exam of the American Midwifery developmental process Certification Board (AMCB), the (3) Promotion of family-centered care student must graduate from a pro- (4) Empowerment of women as partners gram accredited by the Accreditation in health care Commission on Midwifery Education (5) Facilitation of healthy family and in- (ACME) terpersonal relationships (4) Programs accredited by ACME may or (6) Promotion of continuity of care may not require nursing (7) Health promotion, disease preven- (5) Curriculum is based on the ACNM tion, and health education Core Competencies for Basic Mid- (8) Advocacy for informed choice, partici- wifery Practice (2007) patory decision making, and the right (a) Delineate knowledge and skill to self-determination base for entry into midwifery (9) Cultural competency and proficiency practice (10) Skillful communication, guidance, (b) Competencies defined by ACNM and counseling i. Revised through rigorous (11) Therapeutic value of human presence review every 5 years to reflect (12) Value of and respect for differing standards of practice paths toward knowledge and growth ii. Process takes 1 full year (13) Effective communication and col- with opportunity for input laboration with other members of the from membership and is ap- healthcare team proved by the ACNM Board of (14) Promotion of a public healthcare Directors perspective (c) Delineates expected fundamental (15) Care to vulnerable populations knowledge, skills and behaviors c. Practice expected of new midwife, to (1) As a primary healthcare provider, include: provides care that is integrated and i. Hallmarks—art and science of accessible to women and families midwifery (2) Practice is autonomous or collabora- ii. Professional responsibilities tive, and evidence-based iii. Midwifery management (3) Provides health promotion, disease process prevention, counseling, and educa- iv. Fundamentals of midwifery tion across the life span care (4) Diagnoses, treats, and manages com- v. The care of the childbearing mon health problems family (5) Focuses on childbearing, newborn vi. The primary health care of care, postpartum care, family plan- women ning, and gynecological care (6) Accepts accountability for care • The American College of Nurse-Midwives (ACNM) provided 1. Established in 1955 to serve as the profes- (7) Of the various models of practice, sional organization for nurse midwives and private practice in a midwifery group was called the American College of Nurse provides the most autonomy Midwifery (8) Site of practice is in all places where 2. Founded to set the standards for education women’s health care is needed, in- and practice of nurse midwives cluding the home 3. The name changed from American College of d. Education Nurse Midwifery to American College of Nurse (1) Prior to 2010, included postbaccalau- Midwives as a result of merger with American reate certificate, master’s degrees, and Association of Nurse Midwives (AANM) post-master’s certificate programs 4. Purposes of the ACNM (2) Beginning in 2010, all programs will a. Promotion and development of quality be master’s degree, post-master’s cer- care for women and infants tificate, DNP, or other doctoral degree b. Commitment to excellent educational (ACNM, 2009) standards Trends and Issues 341

c. Expansion of knowledge through research 8. Standards of practice (ACNM, 2003) and evaluation a. Standards reflect independent manage- d. Provision of mechanisms for members to ment of women’s health care, with a focus maintain midwifery standards and prac- on pregnancy, childbirth, postpartum pe- tice quality in accordance with ACNM riod, care of neonate, family planning, and philosophy gynecological well-being 5. Structure of the College b. Expansion of competencies beyond basic a. The Board of Directors (BOD), consisting core of President, Vice-President, Secretary, 9. Quality assurance in midwifery Treasurer, and Regional Representatives, a. Peer review encouraged and implemented are elected by the members of the College at local chapter level and make decisions and set policy for the b. Practice outcomes documented with fo- College cused review of unexpected outcomes b. The Executive Director is responsible for c. Midwifery practice mechanisms for col- the day-to-day operation of the organiza- laboration, consultation, and referral tion in the National Office occur via jointly agreed-upon practice c. Housed in the National Office but separate guidelines in budget and function are the Division of 10. Fellowship of the College (FACNM) Accreditation and the ACNM Foundation a. Established in 1993 to honor members d. The midwives’ political action committee whose professional achievements, out- (PAC) is separate in budget but an integral standing scholarship, clinical excellence, part of the ACNM that was established to and/or demonstrated leadership has provide contributions to federal legislators merited them recognition both within and in order to further the interests of CNMs/ outside the midwifery profession CMs and the women’s agenda b. Two categories of Fellowship—Distin- e. Divisions and committees do a vast por- guished Fellows and Fellows tion of the work of furthering the profession and the health care of women • Certification through the College 1. American Midwifery Certification Board f. Regions representing local chapters cover- (AMCB) provides examination for graduates of ing all 50 states and US territories facilitate ACME-accredited programs communication between Board of Direc- 2. All CNMs/CMs certified after January 1996 tors and members receive time-limited certificates that must be 6. Functions of the College renewed; effective January 1, 2011 all CNMs/ a. To advocate for the healthcare needs and CMs will have time-limited certificates that well-being of women and families must be renewed every 5 years b. To further the interests of the profession of 3. AMCB implements a Certificate Maintenance midwifery while maintaining the highest Program (CMP) for all CNMs/CMs who need standards of practice and education recertification c. To protect and enhance the rights of 4. AMCB-certified midwives (nonnurse) practice members legally in New York, New Jersey, and Rhode 7. Continuing Competency Assessment (CCA) Island program—voluntary program whose purposes are (as of September 1, 2010, the CCA program Â Trends and Issues will no longer be available): a. To assure continuing professional educa- • Those common to both NPs and CNMs/CMs tion based on a 5-year cycle 1. Healthy People 2010 initiatives (DHHS, 2000) b. To assist CNMs in providing documen- a. Prevention agenda for the nation to in- tation of appropriate credential main- crease years of healthy life while reducing tenance to state licensing bodies and health disparities hospital credentialing units b. Objectives significant as leading national c. To foster development of methods of health indicators competency assessment that evaluate c. Origin is the 1979 Surgeon General’s report psychomotor, cognitive, and affective do- on health promotion and disease preven- mains of midwifery practice tion entitled “Healthy People” 342 Chapter 9 Advanced Practice Nursing and Midwifery: Role Development, Trends, and Issues

d. Healthy People 2010 c. The American Nurses Association, Ameri- (1) Delineates 10 leading health indica- can Academy of Nurse Practitioners, Na- tors that will be used to measure the tional Association of Nurse Practitioners health of the nation over the next 10 in Women’s Health, American College years of Nurse Midwives, and other advanced (2) More extensive work underway on is- nursing practice organizations provide sue of expanding leading health indi- leadership to establish the following: cators with purpose of extending the (1) Delivery systems that assure acces- reach of Healthy People sible, quality, and affordable services (3) Healthy People 2020 will be released (2) Availability of basic and essential in two phases health services to all individuals (a) Framework (vision, mission, (3) Support of primary care goals, focus areas, and criteria (4) Shift from illness/cure focus to for selecting and prioritizing wellness/care focus objectives)—2009 (5) Support for insurance reform that (b) Healthy People 2020 objectives assures access to NPs/midwives and with guidance for achieving the payment for their services new 10-year targets—2010 (6) Collaborative review of resource al- 2. Primary health care and healthcare reform location, cost-reduction plans, and a. Healthcare system reform—four critical reimbursement issues by representa- issues (ANA, 2008) tives from public and private sectors (1) Access—affordable, available, 3. Professional liability insurance acceptable a. Recommended that each clinician carry (2) Quality—safe, effective, patient cen- individual policy tered, timely, efficient, equitable (In- b. Types of coverage stitute of Medicine, 2001) (1) Occurrence—covers event of malprac- (3) Cost—more focus on primary care, tice that occurred during the policy ultimately requiring less secondary period without regard to when the and tertiary care that is more costly; claims are reported; provides protec- privately and publicly funded options for each policy period indefi- tions for standard package of essential nitely; broadest protection available healthcare services (2) Claims made—incident must hap- (4) Healthcare workforce—adequate sup- pen and be reported while policy is in ply of well-educated, well-distributed, force; requires purchase of a tail policy and well-utilized registered nurses to protect, once policy period ends b. Components of primary health care c. Cost of insurance varies with APRN role (1) Entry point to the health system that and population focus provides access to secondary and ter- 4. Scope of practice (Hamric, Spross, & Hanson, tiary care 2009) (2) Care is accessible, comprehensive, a. Definition—describes practice limits and coordinated, continuous, accountable sets parameters within which the APRN (3) Serves as a strategy for organizing may legally practice health care into a system in which b. Scope of practice aspects community-oriented primary care is (1) Defines what is legally allowable delivered (2) Defines what APRN can do with pa- (4) Prioritizes and allocates resources to tients, what he/she can delegate, and community-based care as opposed to when collaboration with others is hospital-based acute care required (5) Providers include family medicine, (3) Scope may differ depending on APRN general internal medicine, pediatri- role—clinical nurse specialist, nurse cians, obstetricians/gynecologists, anesthetist, nurse midwife, nurse certified nurse midwives, nurse prac- practitioner titioners, physician assistants (4) Based on state laws promulgated by (6) Care includes age- and gender- the various nurse practice acts and specific screening for health rules and regulations for APRN—var- promotion/disease prevention as well ies from state to state as diagnosis and treatment of common illnesses Trends and Issues 343

5. Standards of practice Boards of Nursing APRN Advisory a. Definition—the description of the mini- Committee mum levels of acceptable performance for b. Defines APRN practice a profession or specialty c. Describes regulatory model for education, b. Aspects certification, and licensure of advanced (1) Evolves from the scope of practice practice registered nurses (2) Provides specifications for acceptable (1) Four APRN roles—nurse anesthetist, levels of care and a mechanism for nurse midwife, clinical nurse special- determining excellence in care ist, nurse practitioner (3) Provides the framework for develop- (2) Six population foci—family/individual ment of competency statements across lifespan, adult–gerontology, (4) Establishes the educational prepara- neonatal, pediatrics, women’s health, tion for basic practice, and provides psychiatric–mental health a statement of educational outcomes (3) Education, certification, and licensure and standards for organized nursing of individual must be congruent in practice terms of role and population focus (5) Provides quality assurance to con- (4) APRNs may specialize (e.g., acute care, sumers through accreditation and palliative care) but cannot be certified certification standards or licensed solely within a specialty (6) May provide legal expectations of a area practice (5) State boards of nursing will be solely (7) May be developed by specialty groups responsible for licensing APRNs to guide particular aspects of practice d. Identifies titles to be used 6. Nurse practice acts e. Implementation of model will occur incre- a. Definition—legislative enactments that mentally; target date for full implementa- define the practice of nursing, give guid- tion is 2015 ance within the scope of practice issues, 8. Doctor of Nursing Practice (DNP) and set standards for practice; passage a. Practice-focused rather than research- through state legislatures makes these the focused nursing doctoral degree law under which nursing is practiced in b. American Association of Colleges of Nurs- that state ing (AACN) 2004 position statement calls b. Types of practice acts for DNP degree to be required for entry (1) Licensure statutes limit practice to into advanced nursing practice by 2015 individuals with specific qualifications c. DNP Essentials established by AACN as determined by law (2006) for curricular elements and (2) Registration or certification statutes competencies provide a definition and limit as to d. Entry into DNP program may be after who may use title, without restraint of completion of postbaccalaureate nursing practice degree (BS to DNP) or post-master’s nurs- c. Aspects of practice acts ing degree (MS to DNP) (1) Regulated state by state e. Program length varies depending on BS- (2) Authorizes state boards of nursing to to-DNP/MS-to-DNP program type as well establish statutory authority for the as APRN role and population focus licensure of registered nurses, includ- f. Requires a minimum of 1000 hours of ing APRNs supervised postbaccalaureate clinical (3) Authorizes state boards of nursing to experience establish a scope of practice, determine disciplinary actions, and regu- • Trends and issues unique to midwifery late its practice via legislative statutes 1. The ACNM political action committee (PAC) (4) Regulations reflect the trend to in- was established to address critical federal leg- crease APRN authority and autonomy islative issues relating to women’s health and (5) May authorize prescriptive authority the role of CNMs/CMs in delivering quality 7. Consensus model for APRN regulation—Licen- obstetric and gynecological care sure, Accreditation, Certification, and Educa- 2. Primary care role—“With women, for a life- tion (LACE) (2008) time” (ACNM registered tag line) a. Completed by APRN Consensus Work Group and National council of State 344 Chapter 9 Advanced Practice Nursing and Midwifery: Role Development, Trends, and Issues

a. Core Competencies for Basic Midwifery • Privileging Practice (2007) include specific competen- 1. Definition—authorization granted to a practi- cies for primary care tioner by the healthcare network or a compo- b. Nurse midwifery certification examination nent of the network to provide specific patient began to include content for primary care care services that must fall within defined in 2001 limits based upon the LIP’s qualifications and c. Rationale—evolving toward primary care current competence is in best interests of women, since CNMs/ 2. Privileging, either through medical staff or CMs are often their only care providers, allied health staff mechanisms, can put NP and makes CNMs/CMs more congruent and CNM/CM providers on the same level with the current healthcare system with physicians with regard to rights and 3. Cultural competence responsibilities a. CNMs/CMs have always cared for vulner- 3. The Joint Commission modified its standards able populations of women who represent on staff privileges to include nonphysician a wide variety of ethnic and cultural roots providers who were licensed independent pro- b. Concepts of cultural competence are part viders (LIP) of the Core Competencies for Basic Mid- wifery Practice • Practice issues 4. International midwifery 1. Licensure a. Midwifery education and practice vary a. Process by which a government agency between the developed and less devel- authorizes individuals to practice a profes- oped countries with the level of education sion or occupation by validating that the higher in the former individual has attained the required de- b. Even in countries with numerous mid- gree of competency as prescribed by law wives and a long history of professional to protect the public welfare midwifery practice, the profession strug- b. Regulated on state-by-state basis through gles with the continuing trend toward nursing or midwifery practice acts “medicalization” and increased use of 2. Certification technology a. The formal process by which a private c. Midwifery, in most countries, is a separate agency or organization certifies (usually by profession, but where it is associated with examination) that an individual has met nursing, midwifery subsumes nursing standards as specified by that profession rather than midwifery being an arm of (Hamric, Spross, & Hanson, 2009) nursing b. Aspects of certification d. The International Confederation of Mid- (1) Assures the public that an individual wives (ICM) provides midwifery leader- has mastered a body of knowledge ship across nations and acquired skills in a particular specialty to assure quality practitioners Â Professional Components of (2) Used by most states as one compo- Advanced Practice Nursing nent of second licensure for advanced and Midwifery nursing practice (3) Requires or encourages maintenance • Credentialing (institutional and regulatory body of a particular level of competence fol- levels) lowing initial credentialing 1. Definition—the process of assessing and vali- (4) May be used as a mechanism for con- dating the qualifications of a licensed inde- trol of practice pendent practitioner (LIP) to provide member health services in a healthcare network and/or • Prescriptive authority its components 1. Definition—legal authority to prescribe medi- 2. Outcomes cations or devices a. Mandates accountability and responsibil- 2. Authority is contained in state nurse or mid- ity for competence wifery practice acts or in other statutes and b. Assures that care is provided by qualified varies from state to state practitioners 3. May require approval of state board of medi- c. Testifies to compliance with federal and cine, midwifery, public health, or pharmacy state laws regarding nursing and mid- 4. Requires completion of an advanced pharma- wifery practice cology course and continuing education hours d. Acknowledges advanced scope of practice to maintain prescribing status Professional Components of Advanced Practice Nursing and Midwifery 345

5. May require a collaborative practice agree- 2. Organizational activities ment and/or written protocols a. Provides, fosters, and facilitates leadership 6. May obtain federal Drug Enforcement Agency for and among members (DEA) registration number, depending on b. Disseminates information relevant to scope of state law practice c. Monitors and influences laws and • Independent and collaborative management of regulations care d. Produces position papers communicating 1. Independent—care of women within the pro- organizational perspectives on issues of vider’s scope of practice, based on knowledge, concern skills, and competencies e. Establishes practice competencies and 2. Consultation—seeks advice or opinion of a standards and may offer continuing edu- physician or other member of the healthcare cation resources team while the NP/midwife retains primary f. Enhances the visibility of the members responsibility for the woman’s care through marketing, public relation efforts 3. Referral—the process by which the provider g. May construct and maintain a national directs the client to a physician or another database of all provider activities healthcare professional for management of h. Encourages and supports research efforts a particular problem or aspect of the client’s care • Reimbursement 4. Collaboration—NP/midwife and physician 1. Types of reimbursement jointly manage the care of a woman who has a. Fee-for-service—payment in which a developed complications, the goal of which is usual, customary, or reasonable charge to share authority while providing quality care for service as determined by provider is within each individual’s scope of practice submitted b. Fee schedules—predetermined payment • Professional organizations for services in which equal pay for equal 1. Purposes and benefits of membership work prevails, and as a resource-based a. Purposes of professional nursing and mid- schedule may consider practice expenses, wifery organizations provider skills and time, and malpractice (1) Promote and set high standards for expenses health care c. Percentage—percentage either above or (2) Enhance the identity, visibility, and below that listed on the fee schedule is cal- practice of its members culated depending upon who is providing (3) Provide a collective voice to promote the care the profession of midwifery, nursing, d. Capitation—payment is made to the pro- and the APRN role vider for each enrolled patient within a b. Individual benefits managed care organization (MCO), based (1) Membership within a community of on the terms of the contract’s per member like-providers who share commonali- per month (PMPM) costs ties specific to their specialty areas e. Indirect billing—method in which the (2) Networking availability through institution is named as the recipient of participation in local, regional, and payment, and the provider is usually an national meetings, alliances, and employee of the institution coalitions f. Direct billing—method in which the pro- (3) Legislative representation, support, vider is a recognized provider of services and participation at all levels and the payer reimburses on submis- (4) Continuing education programs to sion of a bill; advantages of direct billing attain/maintain clinical competency include: (5) May provide consultation and assis- (1) Increased availability and access to tance in securing federal scholarship health care and loans for continuation of study (2) Increased choice of providers (6) Receipt of organizational publications (3) Reduced restrictions on practice (7) Listings of employment opportunities (4) Potential for cost-effectiveness (8) Professional recognition of excellence (5) Making visible and legitimate the in practice and research APRN and midwifery role 346 Chapter 9 Advanced Practice Nursing and Midwifery: Role Development, Trends, and Issues

Â Health Policy and Legislative emphasis from a fee-for-service strategy to one Regulation of Midwifery and in which the network of providers assumes Nursing some degree of responsibility for both provision and cost of care • Law making 2. Characteristics 1. Definition—activity of state or federal legisla- a. Vertical integration of services tive or lawmaking branch of government in (1) Varying levels of care that are coordi- which proposals or bills specifically define the nated into a seamless system actions or solutions to problems that affect a (2) Patients negotiate the delivery system particular interested party smoothly 2. Outlines strategies for problem resolution, b. Capitated system of payment/prospective suggests timelines for implementation, and pricing attaches proposed budgets to support start-up (1) Financial risk assumed by provider programs (2) Unit of value is cost per member per 3. Law results after concluding specified pro- month (PMPM), determined in ad- cesses through the legislative body and signed vance by contract (prospectively) by the President or state governor (3) Age and gender budget is allotted to 4. Nurse practice acts represent legislative regu- provider lation of advanced practice nursing (4) Provider responsible for this target 5. Midwifery is legislated by nursing, midwifery, population public health, or other statutes; some states (5) To remain financially solvent, target may have two levels of legislation; one for population should be healthy, which nurse midwives and one for midwives who are means that they consume the least not nurses dollars for care provided c. Low cost, high quality service with empha- • Regulatory action sis on health promotion 1. Activity within specified and appropriate gov- (1) Goal of an integrated service ernment agencies in which regulations are (2) Increases value of system to consum- developed that specify how the law is to be ers and payers implemented (3) Service bundling, where complemen- 2. Extremely important since the language of law tary care can be offered as a package, is terse and requires interpretation provided further reduces costs by the regulations d. Resource rationing 3. State professional boards serve as regulatory (1) Primary care provider (PCP) is respon- bodies defining regulations stemming from sible for provision and management law of services (2) Emphasis is on appropriate levels of Â Healthcare Delivery Systems care, but not unlimited care 3. Types of managed care plans • Traditional health care a. Health Maintenance Organization (HMO) 1. Emphasizes independent providers (1) Established under HMO Act of 1973 2. Characteristics (2) Most common plan with focus on pre- a. Providers chosen by patient with little, if ventive care any, influence from third party payer (3) Prepayment of premiums with prees- b. Provider reimbursed by patient and insur- tablished benefit package for care ers in fee-for-service arrangement (4) MCO contracts with PCP to provide c. Insurers reimburse according to usual, care to enrollees, creating incentive customary, and reasonable system, per- for cost-effective care mitting greater latitude in provider rate (5) PCP is selected by enrollee, man- setting ages total care, authorizes specialty visits resulting in designation as • Integrated delivery systems/managed care organi- “gatekeeper” zations (MCOs) b. Preferred Provider Organization (PPO) 1. A health delivery system that strives to pro- (1) A compromise to indemnity and HMO vide high quality, cost-effective care through coverage a coordination of health services historically (2) MCO contracts with independent pro- provided by a variety of caregivers; shifting viders for negotiated fee-for-service Healthcare Delivery Systems 347

(3) Employees have a variety of care ar- b. Part A—hospital insurance rangements as opposed to HMO (1) Funded by payroll tax prepackage (2) Automatic enrollment at age 65 if paid (4) Uses financial incentives to influence for more than 40 quarters; if paid for consumers and providers less than 40 quarters, may enroll by (5) Usually owned by large insurance paying monthly premiums companies (3) If disabled and younger than 65 years, c. Point of Service Plan (POS) may enroll after receiving Social Secu- (1) Considered a variation of HMO and rity benefits for 24 months; preempted PPO if dialysis or transplant required (2) Consumer decides at which point they (4) Limited benefit period require service from a provider other (a) Starts when recipient enters hos- than the one(s) within the plan pital and ends with break of at (3) Costs to consumer are higher when least 60 consecutive days of care “out-of-plan” care received (b) Inpatient hospital care is normally 4. Financial strategies and reimbursement under limited to 90 days during a benefit an MCO period; copayment required from a. Financial arrangements determined pro- days 61 to 90 spectively under terms of contract and (c) No limit to the number of benefit include prospective pricing, service bun- periods in a lifetime dling, price discounts/discounted fees for (5) Services services to certain populations and for (a) Some hospitalization costs and coverage of specific conditions skilled nursing facility (SNF) costs b. Reimbursement based on contract details (b) Home health care, with 100% determined by financing arrangements, coverage for skilled care and 80% target population, and capitated costs coverage for approved medical PMPM equipment c. Provider accepts financial risks, setting the (c) 100% coverage of hospice care in cost and volume, which affects quality and most cases costs c. Part B—supplementary medical insurance d. Efficiency rewarded through bonus system (1) Eligible recipients, as established un- for quality and efficiency der part A, must pay a premium 5. Additional definitions for terms associated (2) Some low-income recipients may with reimbursement and health insurance have premium paid by Medicaid coverage (3) Financed by federal revenues and a. First party is the individual monthly premiums b. Second party is the family (4) Services c. Third party is an insurance company, (a) All medically necessary services fiscal intermediary such as a union ben- are covered at 80% of approved efit fund, or payer such as Medicare or amount after $100 deductible, Medicaid and include provider services, d. Catastrophic coverage is insurance for physical, occupational and expenses beyond a set threshold, such speech therapy, medical equip- as may occur with long-term illness or ment, diagnostic tests disability, or with a technology intensive (b) Preventive services include Pap treatment tests, mammograms, hepatitis B 6. Medicare (Hamric, Spross, & Hanson, 2009) immunization, pneumococcal a. Overview and influenza vaccines (1) Federally mandated program, enacted d. Part C—Medicare+Choice program as Title XVIII of the Social Security Act (1) Established by the Balanced Budget of 1965, entitled “Health Insurance for Act of 1997 (Public Law 105–33) the Aged and Disabled” (2) Beneficiaries must have Part A and be (2) Provides health insurance for those enrolled in Part B older than 65 years and disabled (3) Recipients may choose benefits (3) Eligibility is not currently income through variety of risk-based plans dependent e. Part D—prescription drug coverage (4) Four parts—A, B, C, and D 348 Chapter 9 Advanced Practice Nursing and Midwifery: Role Development, Trends, and Issues

f. Reimbursement to APRNs and CNMs/ (2) Financed through federal and state CMs taxes, with 50–80% of costs covered by (1) Balanced Budget Act of 1997 ex- the federal government panded direct reimbursement to NPs (3) Does not cover all individuals below in all geographic locations at 85% of the poverty level physician fee schedule; CNMs/CMs (4) Federally required state Medicaid cov- are legislated through Medicare law erage; eligibility is set by states for reimbursement at 65% (ACNM, (a) Those older than 65, blind, totally 2003) disabled who are eligible for assis- (a) Removes restriction on type of tance under federal Supplemental area, setting in which services are Security Income (SSI) program paid (b) Pregnant women and children (b) Expands professional services for younger than 6 years of age with APRNs by authorizing them to bill family incomes up to 133% of the directly for services federal poverty level (2) APRN qualifications to be a Medicare (c) Children who are younger than provider age 19, in families whose income (a) Current RN and APRN license to is at or below poverty level practice in state in which services (5) General coverage rendered (a) Hospital and provider services (b) National certification in an ad- (b) Laboratory and radiologic vanced practice nurse role services (c) Master’s degree in nursing (c) Nursing home and home health- (d) National Provider Identifier (NPI) care services number—obtained from Center (d) Prenatal and preventive services for Medicare and Medicaid Ser- (e) Medically necessary vices (CMS) transportation (3) Provision of payment (6) Services can be added to the above (a) Fee-for-service Medicare—APRN and limitations may be placed on fed- submits bills to local Medicare erally mandated services by the states carrier agent for each visit or pro- (7) States may choose to cover the “medi- cedure; NP reimbursed at 85% of cally needy” physician fee for same service (8) Recipients of Medicaid funds cannot (b) Capitated Medicare—fee paid to be billed although they may be re- healthcare provider, per patient, sponsible for nominal copayments or per month, for care of Medicare deductibles patient enrolled in managed care b. Reimbursement—determined by states organization; APRN applies to (1) Operates as a vendor payment pro- MCO to be on panel of providers gram with broad discretion in deter- (c) “Incident to” services—services mining methodology at the state level are billed at 100% under supervis- (2) Providers must accept Medicaid paying physician’s national provider ment rates as payment in full identifier (NPI) number; physi- (3) Omnibus Budget Reconciliation Act cian must be present in office (OBRA) (1989) suite; does not include APRN (a) Mandated Medicaid reimburse- seeing patient for an initial visit ment for pediatric nurse practitio- or subsequent visit with a new ner (PNP), certified nurse midwife problem; physician must demon- (CNM), and family nurse practi- strate ongoing participation in the tioner (FNP) management of the patient’s care (b) Must practice within scope of 7. Medicaid (Hamric, Spross, & Hanson, 2009) state law and are not required to a. Overview be under supervision or associa- (1) Enacted as Title XIX of the Social Se- tion with a physician curity Act of 1965 through a system of (c) Level of payment determined by federal and state matching funds, with states, with usual range of 70– federal oversight 100% of physician fee schedule and may bill Medicaid directly Ethical and Legal Issues and Principles 349

(d) States have option of includ- • Ethical principles ing other NP specialties for 1. Autonomy—personal freedom and self deter- reimbursement mination; the right to choose course (e) States can apply for “Medicaid 2. Beneficence—the actions one takes should waivers” to enroll patients cov- promote good ered by Medicaid in MCOs 3. Nonmaleficence—one should do no harm (f) APRN must apply to state Medi- 4. Veracity—one should tell the truth caid agency to be a fee-for-service 5. Fidelity—keeping one’s promises or provider; must apply to the MCO commitments to be included on provider panel 6. Paternalism—allows one to make decisions for (4) Payment to hospitals another; allows no collaboration (a) Based on predetermined fee 7. Justice—fair and equal treatment schedule for projected cost of care 8. Respect for others—highest ethical principle (b) States are mandated to make ad- that incorporates all others ditional payments to hospitals with “disproportionate share • Legal concerns and legal liabilities in providing hospital” (DSH) adjustments for care disproportionate numbers of 1. Law—“That which is laid down, ordained or Medicaid recipients established. Law, in its generic sense, is a body (c) APRN not paid directly for inpa- of rules of action or conduct prescribed by tient services controlling authority, and having binding legal (d) All other forms of insurance must force” (Black’s Law Dictionary, 1990) be exhausted before Medicaid will 2. Tort law—a branch of civil law that concerns cover expenses legal wrongs committed by one person against 8. State Children’s Health Insurance Program another; an act that causes harm to body or (SCHIP) property and for which the injured party is a. Extends insurance to children in low- seeking monetary damages; includes malprac- income families who have too much tice, negligence (Black’s Law Dictionary, 1990) income to be eligible for Medicaid but a. Malpractice—professional misconduct or not enough to be able to afford health unreasonable lack of skill or fidelity in pro- insurance fessional duties; disregard of established b. Funding is federal with a set proportion rules and principles, neglect or malicious matched by state funds intent; the wrong must result in injury, un- c. Managed by states necessary suffering or death; falls under d. Three different mechanisms used by tort law (Black’s Law Dictionary, 1990) states—expanded Medicaid programs, b. Negligence—a general term, indicating separate child health insurance plans, and conduct lacking in due care; carelessness; combination plans doing something any reasonable, prudent person would not do (Black’s Law Dictio- Â Ethical and Legal Issues nary, 1990) and Principles c. Intentional tort—a volitional or willful act, with expressed intent to bring about the • Ethics and the law acquired consequences for which causa- 1. Law is founded on rules that guide a society, tion to act is present regardless of personal views and values (1) Assault—“Places another in appre- 2. Ethical values are impacted by moral, philo- hension of being touched in offensive, sophical, and individual interpretation insulting, or physically injurious man- 3. These areas intertwine creating dilemmas in ner” (Guido, 2005) the provision of health/medical care (2) Battery—actual contact with another 4. MORAL model of ethical decision making without valid consent (Guido, 2005) a. Manage the dilemma—define issues, con- (3) False imprisonment—“Unjustifiably sider options, identify players detaining a person without legal war- b. Outline the options—examine these fully rant to do so” (Guido, 2005) c. Resolve the dilemma—apply basic ethical (4) Intentional infliction of emotional principles to each option distress—“Displays conduct that goes d. Act by applying the chosen option beyond that allowed by society, that is e. Look back and evaluate the entire process 350 Chapter 9 Advanced Practice Nursing and Midwifery: Role Development, Trends, and Issues

calculated to cause mental distress” 2. Legal basis for right to refuse (Guido, 2005) a. Common law right to freedom from non- d. Negligence tort—an act of negligence re- consensual invasion of bodily integrity; quiring that the following four elements embodied in the informed consent doc- be present (Guido, 2005): trine and the law of battery (1) Duty—the responsibility to act in ac- b. Constitutional right of privacy cordance with a standard of care c. Constitutional right to freedom of religion (2) Breach of duty—violation or deviation d. Legally supported by 1990 Supreme Court from the standard of care ruling in Cruzan v. Director, Missouri (3) Causation—determination of whether Department of Health that competent in- the injury is the result of negligence dividuals have the constitutional right to (4) Damages—must be actual harm to the refuse life sustaining treatment person or property 3. Includes “Do Not Resuscitate” (DNR) orders, 3. Confidentiality—derived from the ethical prin- refusal for extraordinary care, and implemen- ciple of justice; protects the patient’s right to tation of supportive-care-only guidelines privacy by requiring that any health information to be shared must first be released by the • Withdrawal of treatment—the decision to ter- patient; “treated as private and not for publica- minate treatment that has been initiated after tion” (Black’s Law Dictionary, 1990) securing informed consent from a patient or their 4. Consent—a legal action given by a patient to representative, with the legal basis for decision and undergo particular treatments and/or proce- subsequent care as noted in refusal of treatment dures; foundation for consent requirement is the tort law of assault, battery (Black’s Law • Coworker incompetence—a legal obligation exists Dictionary, 1990; Guido, 2005) for a licensed professional to assist, relieve. or re- a. Expressed consent—given by spoken or port any coworker who through substandard care written words or impairment places the health and welfare of b. Implied consent—that which arises by patients at risk; official processes relevant to con- reasonable inference from the patient’s tinued practice are determined through agencies conduct and state boards, based on practice act regulations c. Informed consent—given following an opportunity for the patient to have described Â Health Insurance Portability the full scope of the procedure, including and Accountability Act of possible outcomes, thus permitting the 1996 (HIPAA)—Public Law opportunity to evaluate the options and 104–191 associated risks; contains conditions that the patient acted voluntarily, received full • Purpose of HIPAA provisions—improve efficiency disclosure, and is competent to act (Black’s and effectiveness of healthcare system by stan- Law Dictionary, 1990) dardizing the electronic exchange of administra- 5. Proof of liability—evidence that a professional tive and financial data relationship was entered into with subsequent proof of breach of the standard of care • Mandated standards: 6. Statute of limitations—any law that fixes the 1. Specific transaction standards (claims, enroll- time within which parties must take judicial ment, etc.) including code sets action to enforce rights or forfeit these if limits 2. Security and electronic signatures are exceeded (Black’s Law Dictionary, 1990) 3. Privacy 7. Discovery rule—a rule by which patients have 4. Unique identifiers, including allowed uses, 2 years from the time they become aware of for employers, health plans and healthcare the injury to file a complaint; a limitation stat- providers ute (Black’s Law Dictionary, 1990) • Privacy rule • Refusal of treatment 1. Definition—privacy regulations control the 1. Definition—the inherent right of conscious use and disclosure of a patient’s Protected and mentally competent individuals to refuse Health Information (PHI) where the informa- any form of treatment either personally or tion could potentially reveal the identity of through her/his health proxy or acceptable the patient. HIPAA regulates PHI by health- personal representative care providers, health plans, and healthcare clearinghouses, i.e., entities that process or Health Insurance Portability and Accountability Act of 1996 (HIPAA) 351

facilitate the processing of nonstandard data of PHI made in the 6 years or less prior elements of health information into standard to date requested elements or vice versa (5) Request restrictions—individual may 2. Goals of privacy rule request restrictions on uses and dis- a. Provide strong federal protections for pri- closures of PHI, but covered entity vacy rights may disagree b. Preserve quality health care (6) Confidential communication—pro- 3. Protected health information—all information vider must permit and accommodate a. Individually identifiable health infor- reasonable requests to receive com- mation—health and demographic info; munications of PHI by alternative includes physical or mental health, means and at alternative locations the provision of or payment for health (7) Complaints to covered entity—a pro- care; identifies the individual (includes cess must be established to document deceased) complaints and their disposition b. Transmitted or maintained in any form or (8) Complaints to Secretary (HHS/ medium by a covered entity or its business OCR)—any person may file a written associate complaint if they believe a covered en- 4. Key elements of the privacy rule tity is not complying with the privacy a. Covered entity—healthcare providers who rule transmit any health information electroni- 6. De-identification of PHI cally in connection with claims, billing a. Removal of certain identifiers so that the or payment transactions; health plans; individual may no longer be identified healthcare clearinghouses b. Application of statistical method OR b. Uses and disclosures of information c. Stripping of listed identifiers such as (1) Required names, geographic subdivisions, dates, (a) To individual when requested; to SSNs HHS 7. Administrative requirements (b) To investigate or determine com- a. Implement policies and procedures re- pliance with privacy rule garding PHI that are designed to comply (2) Permitted with the privacy rule (a) Individual b. Implement appropriate administrative, (b) Treatment, payment and health- technical, and physical safeguards to pro- care operations (TPO) tect the privacy of PHI (c) Opportunity to agree or object c. Provide privacy training to all workforce (d) Public policy and develop and apply a system of sanc- (e) “Incident to” tions for those who violate the privacy rule (f) Limited data set d. Designate a privacy official responsible for (g) Authorized policies and procedures and for receiving 5. Individual rights complaints a. Notice of privacy practices—must contain e. Compliance and enforcement—effective language in the rule describing uses and April 14, 2003 disclosures of PHI f. Office for Civil Rights (OCR) enforces the b. Individual rights and how to exercise privacy rule them; provide information as follows: 8. Complaint process (1) Covered entity duties and contact a. Informal review may resolve issue fully name, title, or phone number to re- without formal investigation; if not, begin ceive complaints with effective date investigation (2) Access—right to inspect and obtain a b. Technical assistance copy of PHI in a designated record set 9. Civil Monetary Penalties (CMPs) (DRS) in a timely manner a. $100 per violation (3) Amendment—individual has right to b. Capped at $25,000 for each calendar year have covered entity amend PHI; re- for each identical requirement or prohibi- quest may be denied by covered entity tion that is violated if record is accurate and complete c. Criminal penalties for wrongful (4) Accounting—individual has right to disclosures receive an accounting of disclosures (1) Up to $50,000 and 1 year imprisonment 352 Chapter 9 Advanced Practice Nursing and Midwifery: Role Development, Trends, and Issues

(2) Up to $100,000 and 5 years if done un- study, D indicates the study has a major flaw that der false pretenses raises serious questions about the believability of (3) Up to $250,000 and 10 years if intent the findings to sell, transfer, or use for commercial advantage, personal gain, or malicious Note—The author would like to thank Dorothy Atkins, harm MS, RNC, WHNP for her contributions to this chapter. (4) Enforced by Department of Justice (DOJ) Â Questions Select the best answer. Â Evidence-Based Practice 1. The Healthy People initiative can best be • Definition—the conscientious, judicious, and described as: explicit use of current best evidence in making decisions about the care of individual patients, incor- a. An outline of available health data porating both clinical expertise and patient values b. Standards for organized health care c. A prevention agenda and benchmark for • Major clinical categories of primary research and health their preferred study designs d. A legislative health initiative enacted by 1. Therapy—tests the effectiveness of a treat- Congress ment; randomized, double-blinded, placebo- 2. Healthy People 2010 focuses on: controlled 2. Diagnosis and screening—measures the va- a. Identification of health problems specific to lidity and reliability of a test or evaluates the populations effectiveness of a test in detecting disease at a b. Prevention to increase years of healthy life presymptomatic stage—cross-sectional survey c. Trends in health delivery systems 3. Causation or harm—assess whether a sub- d. Extension of existing health indicators stance is related to the development of an ill- 3. Which of the following characteristics is not asso- ness or condition—cohort or case-control ciated with primary health care? 4. Prognosis—determines the outcome of a disease—longitudinal cohort study a. Accessible, comprehensive, coordinated care 5. Systematic review—a summary of the litera- b. Community-based care ture that uses explicit methods to perform c. Development of provider–patient a thorough literature search and critical ap- partnerships praisal of individual studies and that uses ap- d. Allocation of resources to specialty groups propriate statistical techniques to combine 4. Which of the following is not one of the six these valid studies population foci for APRN established by the con- 6. Meta-analysis—a systematic review that uses sensus model for APRN regulation? quantitative methods to summarize results a. Critical care • Categories of strength of reviewed evidence from b. Neonatal care individual research and other sources c. Pediatrics 1. Level I (A–D)—Meta-analysis or multiple con- d. Women’s health trolled studies 5. Which of the following statements concerning 2. Level II (A–D)—individual experimental study the Doctor of Nursing Practice (DNP) program is 3. Level III (A–D)—quasi-experimental study correct? 4. Level IV (A–D)—nonexperimental study 5. Level V (A–D)—case report or systematically a. It requires a minimum of 500 hours of super- obtained, verifiable quality, or program evalu- vised clinical experience. ation data b. Individuals must already be certified as an 6. Level VI—opinion of respected authorities; this APRN before entry into the DNP program. level also includes regulatory or legal opinions c. The program focus is on practice more so than research. • Level I is the strongest rating per type of research; d. The DNP Essentials were developed by however, quality for any level can range from A professional advanced practice nursing to D and reflects basic scientific credibility of the organizations. overall study; A indicates a very well-designed Questions 353

6. The Hallmarks of Midwifery would not allow for 12. Once a bill is enacted into law, the particular which of the following? aspects of that law must be defined and implemented. The next step in this process is: a. Advocacy of regular use of technologic interventions a. Review by the state’s oversight committee b. Informed choice with participatory decision b. Assignment to a regulatory agency making c. Approval by the federal government c. Therapeutic value of human presence d. Legislative hearings to determine the best d. Recognition of women’s life phases as disposition of the law normal, developmental processes 13. The goal of an integrated system of health care is: 7. Prescriptive authority in all states requires that a. Control of costs through member selection the APRN: b. Reduction of costs through employment of a. Complete specified pharmacologic educa- fewer physicians tional requirements c. To make available unlimited health services b. Obtain a drug enforcement agency (DEA) under one plan registration number d. To provide low cost–high quality service c. Obtain a national provider identifier number 14. The primary care role in midwifery: d. Practice under a collaborative agreement with a physician a. Has been an essential part of practice since 1970 8. The nongovernmental validation of a nurse prac- b. Is limited to the promotion of health and titioner’s or midwife’s knowledge and acquired prevention of disease skills in a particular APRN role and population c. Is not appropriate to midwifery practice since focus is: education does not include it a. Licensure d. Has evolved over time and in 2001 was b. Credentialing included in the certification examination c. Certification 15. Which of the following best describes capitation d. Registration as a financial strategy? 9. The best source of information on APRN-specific a. Predetermined payment for services based requirements for prescriptive authority is: on an accepted schedule of fees a. Federal Drug Enforcement Agency (DEA) b. Predetermined fees set for usual and cus- b. Professional APRN organizations tomary care c. State boards of nursing c. Predetermined payment based on contrac- d. State boards of pharmacy tual per member per month rate d. Predetermined rates negotiated monthly for 10. A piece of state legislation affecting nurse prac- each participating member titioner or midwifery practice is due to come to a vote. Which of the following would provide you 16. The purpose of HIPAA is to: the most efficient and most dramatic statement a. Decrease the expenses and therefore the regarding your support of the bill? costs of healthcare delivery a. A letter to your congressman b. Improve the health system by standardizing b. Your testimony as a member of your profes- the exchange of electronic data sional organization c. Reimburse providers and laboratories in a c. Your independent testimony timely fashion d. Your support for a nurse practitioner or mid- d. Assure that every person has ready access to wifery organization and their PAC appropriate health care 11. A vote is taken and your bill wins! This is an 17. A covered entity under HIPAA is: example of: a. A health provider who transmits any health a. Legislative action information electronically b. Regulatory action b. Any healthcare provider whose case load is c. Judicial success greater than 500 d. Executive authority c. Government entities, either state or federal, that provide insurance d. Teaching hospitals that provide care for Medicaid patients 354 Chapter 9 Advanced Practice Nursing and Midwifery: Role Development, Trends, and Issues

18. The goal of the privacy rule of HIPAA is to: 24. Which of the following statements concerning “incident to” billing is correct? a. Provide federal protections for privacy and preserve quality care a. It applies to both Medicare and Medicaid b. Assure that research subjects’ privacy is main- billing. tained during the study b. It can be used when APRN sees a patient for c. Guarantee that the privacy of patients is pro- any visit other than the initial visit. tected at any cost c. It promotes the visibility and status of d. Increase the level of confidentiality in Medi- advanced practice nurses. caid programs d. It requires that the physician demonstrate ongoing involvement in the patient’s care. 19. One of the principle differences between Medi- care Parts A and B is: 25. Keeping one’s promises or commitments is: a. Eligibility a. Beneficence b. Rate of reimbursement b. Fidelity c. Monthly premium requirement for Part A c. Veracity d. Monthly premium requirement for Part B d. Justice 20. Managed care organization (MCO) characteristics 26. Mrs. G. wants to have her health record sent to include all of the following except: another provider. Under HIPAA, she: a. Capitated system of payment a. Has to indicate in writing her wish to have b. Opportunity for service bundling this sent to another provider c. Payment to APRN restricted to “incident to” b. Cannot share her information with anyone billing outside the provider organization d. Some financial risk assumed by the provider c. Can call on the phone and provide the name and address of the provider 21. Under the Balanced Budget Act of 1997, nurse d. Will have her husband pick up the copy on practitioners with Medicare provider status: his way home from work a. Receive reimbursement at 85% of physician 27. During a malpractice hearing, an attorney payment for services provided describes the responsibility “to do no harm.” The b. Must become a member of a managed care attorney is defining the ethical principle of: organization to receive reimbursement c. Can no longer bill using “incident to” a. Justice provision b. Veracity d. Can receive direct reimbursement under c. Fidelity Medicare Part D d. Nonmaleficence 22. A national provider identifier (NPI) number can 28. A nurse practitioner or midwife fails to order a be obtained from: test that is clinically indicated. This omission is best described as: a. Centers for Medicare and Medicaid Services (CMS) a. Maleficence b. Drug Enforcement Agency (DEA) b. Assault c. Managed care organization (MCO) c. An intentional tort d. State board of nursing d. Negligence 23. All states are required to provide Medicaid to: 29. A patient presents with an abnormal test result. The appropriate plan of care is to refer for addi- a. Pregnant women and children younger than tional testing, but the facility that performs the 6 years of age test has closed for the day. Rather than sending b. Families eligible for state children’s health the patient to have the test performed at the insurance program (SCHIP) hospital, the nurse practitioner or midwife in c. Children younger than19 years, in families the practice orders the patient to report to who are up to 125% of the federal poverty the testing facility the next morning. During level the evening, problems arise and the patient d. Individuals older than 65 years with a chronic is admitted to the hospital with a negative medical condition that are below the federal outcome. This is an example of: poverty level Questions 355

a. An intentional tort 36. The Sheppard-Towner Act of 1921 was enacted b. A negligence tort to: c. Breach of duty only a. Provide payment to midwives d. Withdrawal of treatment b. Regulate immigrant midwives 30. Performing a pelvic examination on a mentally c. Improve maternal infant care disabled patient who cannot give consent may d. Start a program of education for new constitute: midwives a. Assault 37. The American College of Nurse Midwives (ACNM) b. Battery was founded to: c. Intentional tort a. Provide education for untrained midwives d. Paternalism b. Set the standards for practice and education 31. The law that establishes a time frame within of nurse midwives which legal action must be initiated is known as: c. Import nurse midwives from England d. Formally prepare nurses in obstetrics a. The discovery rule b. The proof of liability 38. A midwife, licensed by a state, could be any of c. The statute of limitations the following except: d. The claims made period a. Doula 32. An elderly woman enters a nursing home fol- b. CNM lowing a broken hip and signs “DNR” orders and c. CPM refusal for extraordinary care. She is: d. CM a. Exercising her right to refuse treatment 39. The power to make decisions in the ACNM b. Exercising her right to withdraw treatment resides in the: c. Acting in a manner that should cause a. Executive Director concern about her mental competence b. Board of Directors d. Lacking information needed to make an c. Department Directors informed decision d. Members 33. A women’s health nurse practitioner receives a 40. Components of basic midwifery practice are call from an attorney who tells her she is named delineated in the: in an OB suit that occurred 8 years ago. When she calls the insurance company, she is told that a. Continuing Competency Assessment Program the policy she had at that time will not cover her b. AMCB certification exam because the policy was: c. ACNM by-laws d. ACNM Core Competencies a. A claims made policy b. Tail insurance only 41. Established penalties for violation of HIPAA reg- c. An occurrence policy ulations include: d. An HMO policy a. Community service and license suspension 34. Randomized controlled trials (RCTs) are most b. Up to $50,000 and 1 year imprisonment for appropriate for what type of research study? wrongful disclosures c. Loss of employment and loss of license a. Diagnosis and screening d. The federal agency has not defined specific b. Therapy penalties c. Causation or harm d. Prognosis 42. According to the consensus model for APRN, what entity will be responsible for licensing 35. The category of research that is strongest and APRNs? reflects good study quality is: a. Advanced practice professional organizations a. Level VI (D) b. Individual state boards of nursing b. Level I (D) c. National certification agencies c. Level I (A) d. National Council of State Boards of Nursing d. Level VI (A) 356 Chapter 9 Advanced Practice Nursing and Midwifery: Role Development, Trends, and Issues

43. The midwives’ PAC of the ACNM was established American Academy of Nurse Practitioners (AANP). to: (2007). Scope of practice for nurse practitioners. Wash- ington, DC: Author. a. Contribute to federal legislators to further American Academy of Nurse Practitioners (AANP). the interests of CNMs/CMs (2007). Standards of practice for nurse practitioners. b. Lobby state legislatures on midwifery issues Washington, DC: Author. c. Increase the economic reserves of the American Association of Colleges of Nursing (AACN). College (2006). The essentials of doctoral education for ad- d. Lobby Congress regarding midwifery issues vanced nursing practice. Washington, DC: Author. 44. Which type of midwifery practice provides the American College of Nurse-Midwives (ACNM) Position greatest autonomy? Statement. (2009). Mandatory degree requirements for midwives. Silver Spring, MD: Author. a. Tertiary hospital practice American College of Nurse-Midwives (ACNM) Posi- b. MD/CNM or CM practice tion Statement. (2008). Midwifery certification in the c. Community hospital practice United States. Silver Spring, MD: Author. d. Private midwifery practice American College of Nurse-Midwives (ACNM). (2008). Code of ethics for certified nurse-midwives. Retrieved Â Answers on May 19, 2010 from http://acnm.org. American College of Nurse-Midwives (ACNM). (2007). â 1. c 23. a The core competencies for basic midwifery practice. â 2. b 24. d Retrieved on May 19, 2010 from http://acnm.org. â 3. d 25. b American College of Nurse-Midwives (ACNM). (2005). â 4. a 26. a Standards for the practice of midwifery. Retrieved on â 5. c 27. d May 19, 2010 from http://acnm.org. â 6. a 28. d American College of Nurse-Midwives (ACNM). (2004). ACNM philosophy. Retrieved on May 19, 2010 from â 7. a 29. b http://acnm.org. â 8. c 30. b American College of Nurse-Midwives (ACNM). (2003). â 9. c 31. c ACNM mission statement. Retrieved on May 19, 2010 10. b 32. a from http://acnm.org. 11. a 33. a American College of Nurse-Midwives (ACNM). 12. b 34. b (2003). Joint statement of practice relations be- 13. d 35. c tween obstetricians/gynecologists and CNM/CMs. 14. d 36. c Retrieved on May 19, 2010 from http://acnm.org. 15. c 37. b American College of Nurse-Midwives (ACNM) Position Statement. (1997). Certified nurse-midwives and cer- 16. b 38. a tified midwives as primary care providers/case man- 17. a 39. b agers. Silver Spring, MD: Author. 18. a 40. d American Nurses Association (ANA). (2008). ANA’s 19. d 41. b health system reform agenda. Silver Spring, MD: 20. c 42. b Author. 21. a 43. a Association of Women’s Health, Obstetric, and Neo- 22. a 44. d natal Nurses (AWHONN) and National Association of Nurse Practitioners in Women’s Health (NPWH). (2008). The women’s health nurse practitioner: Guide- Â Bibliography lines for practice and education (6th ed.). Washing- ton, DC: Authors. Advanced Practice Registered Nurse (APRN) Consensus Barker, A. (2009). Advanced practice nursing: Essential Work Group and National Council of State Boards of knowledge for the profession. Sudbury, MA: Jones and Nursing APRN Advisory Committee. (2008). Consen- Bartlett. sus model for APRN regulation: Licensure, accredita- Buppert, C. (2008). Nurse practitioner’s business prac- tion, certification, and education. Retrieved on May tice and legal guide (3rd ed.). Sudbury, MA: Jones and 19, 2010 from http://www.aanp.org. Bartlett. Ament, L. (2007). Professional issues in midwifery. Sud- Department of Health and Human Services (DHHS). bury, MA: Jones and Bartlett. (2009). Developing healthy people 2020. Retrieved on May 19, 2010 from http://www.healthypeople.gov. Bibliography 357

Department of Health and Human Services (DHHS). Varney, H., Kreibs, J., & Gegor, C. (2004). Midwifery (4th (2000). Healthy people 2010 and leading health indi- ed.). Sudbury, MA: Jones and Bartlett. cators. Washington, DC: Government Printing Office. Ventre, F. et al. (1995). The transition from lay midwife Guido, G. W. (2005). Legal and ethical issues in nursing to certified nurse-midwife in the United States. Jour- (5th ed.). Stamford, CT: Appleton & Lange. nal of Nurse-Midwifery, 40(5), 428–437. Hamric, A., Spross, J., & Hanson, C. (2009). Advanced nursing practice: An integrative approach (4th ed.). Philadelphia, PA: W. B. Saunders.

Index

Pages followed by t or f denote tables or figures respectively.

A Acquired anemias, 117 Adrenergic excess hypoglycemia, 297 ABCD guide to malignant melanoma Acquired immune deficiency syndrome Advanced practice registered nurse (APRN). diagnosis, 316, 317 (AIDS), 112, 286, 287 See APRN (advanced practice ABCDEs of domestic violence intervention, Acquired immunity of newborn from registered nurse) 322 mother, 137 Adverse reactions to medications, 30–31. ABCs memory aid, 2–3 Acronyms as memory aids, 2 See also specific disorders/problems ABCs of resuscitation, 138 Acrostics as memory aids, 2 AFP (alphafetoprotein) testing, 88 Abdomen Actinomyces from IUC and Pap test AGC (atypical glandular cells) on Pap test, and aging, 29 predictiveness, 235–236 235, 236 at onset of labor and delivery, 165–166 Active labor, defined, 168 Age factor physical exam, 16, 87 Active TB disease (ATBD), 267, 268, 269 advanced maternal age, 163 postpartum changes, 186 Activity level during labor, assessing gestational age of newborn, 82, 143–144 postpartum checkup, 187 appropriate, 166 health assessment and promotion, 29–30 Abnormal Pap test, 235 Acute cholecystitis, 280, 281 in labor and delivery situation, 163 ABO incompatibility, 116, 152 Acute otitis media, 260–261 Agglutination inhibition test, 47 Abortion, 59, 60, 69–70, 99–101 Acute pyelonephritis, 222, 223 a-glucosidase inhibitors, 296t Abortive therapy for migraines, 309 Acute stress disorder (ASD), 319 Agoraphobia, 319 Abortus, defined, 86 Acute suppurative cholangitis, 280 AIDS (acquired immune deficiency Absence seizure, 311, 312 Acyanotic heart disease, 153 syndrome), 112, 286, 287 Abstinence as contraceptive method, 67–68 Addictive disorders, 324–325. See also AIS (adenocarcinoma in situ), endocervical, Abstinence syndrome for opiate Substance dependency and abuse 235, 236 intoxication in newborn, 152 Adenomyosis, 202–203 Alcohol use and abuse, 97–98, 152, 325 Accreditation Commission for Midwifery Adenosis in breast, defined, 224 Alert state in newborn, 145 Education (ACME), 339, 340, 341 Admission vs outpatient management Allergic conjunctivitis, 257, 258 ACE inhibitors, 247, 249t decision, 166 Allergic contact dermatitis, 315 Acetaminophen, 261 Adolescents Allergic rhinitis, 255, 256t ACHES warning signs with COC use, 52 DUB, 204 Allergies, 255, 256t, 257–258, 266, 315 Acid reducers, 282 and fibroadenoma, 225 Allylamines, 317–318 ACME (Accreditation Commission for history collection from, 12 Alosetron, 274–275 Midwifery Education), 339, 340, 341 intrapartum considerations for, 163 Alpha-adrenergic blockers, 248t Acne, 313–315 puberty developments, 38–39 Alphafetoprotein (AFP) testing, 88 ACNM (American College of Nurse Adrenal hormones, 40 Alveoli, 37 Midwives), 339, 340–341 Adrenarche, 39 Ambiguous genitalia, 154

359 360 Index

Amenorrhea, 67, 188, 199–200, 203 Anticholinergic agents, 256t, 274, 298 Atypical squamous cells of undetermined American College of Nurse Midwives Antidepressants, 321 significance (ASC-US), 235, 236 (ACNM), 339, 340–341 Anti-epileptic drugs, 310t Atypical squamous cells—cannot exclude American Midwifery Certification Board Antifungal preparations for tinea, 317–318. HSIL (ASC-H), 235, 236 (AMCB), 339, 340, 341 See also Azoles Auscultation technique of examination, 13 AMH (antimüllerian hormone), 227 Antihistamines, 256t, 257, 260, 315 Autoimmune disorders Amniocentesis, 94 Antimotility agents, 272 Graves’ disease, 298, 299 Amniochorionic sac (“bag of waters”), 80 Antimüllerian hormone (AMH), 227 Hashimoto’s thyroiditis, 300 Amnion, 80 Antirefluxants/alginic acid, 282 rheumatoid arthritis, 291–293 Amniotic fluid, 80, 81, 96, 107, 179 Antiretroviral therapies for HIV, 288, 289t SLE, 290–291 Amphetamines, abuse affects on newborn, Antisecretory agents, 272 and vulvar dermatoses, 232 152 Antithyroid drugs, 299 Autonomy as ethical principle, 349 Analgesics. See also NSAIDs (nonsteroidal Antiviral therapies, 104, 114, 217, 278, 288, Autosomal dominant genetic anti-inflammatory drugs) 289t abnormalities, 102 acute otitis media, 261 Anxiety, 318–320 Autosomal recessive genetic abnormalities, fibromyalgia, 306 Apgar scoring system, 138, 178 102 for labor pain management, 167, Apnea hypothesis for SIDS, 155 Autosome, defined, 102 169–170, 174 Appendicitis, 118, 275 AWHONN (Association of Women’s Health, Analysis thinking process, 1, 3 Application thinking type, 1, 3, 6–7 Obstetrics and Neonatal Nurses), Androgen insensitivity/resistance APRN (advanced practice registered nurse). 338 syndrome, 227–228 See also Midwifery; NP (nurse Azelaic acid, 314 Android pelvic type, 83, 165 practitioner) Azoles Anemia of chronic disease, 282, 283, 284, credentialing, 344 fluconazole, 213 285 definition, 337 itraconazole, 318 Anemias, 117–118, 282–286. See also Sickle independent and collaborative care metronidazole, 105, 211, 212, 222 cell anemia (SS disease) management, 345 PPIs, 277 Anencephaly, 153 legislative and regulatory policy, 346 sulfamethoxazole, 111, 260 Anesthesia for labor pain management, Medicare qualification criteria, 348 terconazole, 232 167, 170, 173, 174 practice issues, 344 for thrush, 148 Aneuploidy, defined, 102 prescriptive authority, 344–345 for tinea, 317 Angina pectoris, 254–255 privileging, 344 tinidazole, 212 Angiotensin II receptor blockers, 247, 249t professional organizations, 345 Anorexia nervosa, 323–324 reimbursement issues, 345 B Anovulation, 201, 204 roles overview, 337–339 Backache in pregnancy, 89. See also Low Antacids, 282 Areola, 37 back pain (LBP) Antagonistic drug interaction, 31. See also ART (assisted reproductive technology), 234 Bacterial conjunctivitis, 257, 258 specific disorders/problems ASC-H (atypical squamous cells—cannot Bacterial infections in newborn, 150 Antepartum care. See also Pregnancy exclude HSIL), 235, 236 Bacterial vaginosis (BV), 105, 211–212, 235 family issues, 91–93 ASC-US (atypical squamous cells of Balanced Budget Act (1997), 347, 348 fetal assessment, 93–96 undetermined significance), 235, Ballard scale, 143 nutrition, 90–91 236 Barett’s esophagus, 282 overview, 86–89 ASD (acute stress disorder), 319 Barrier contraceptive methods, 61–65, 69, pharmacologic considerations, 93 Asherman’s syndrome, 199 187 review of at time of labor and delivery, Assault in tort law, defined, 349 Basal body temperature (BBT) fertility 164 Assisted reproductive technology (ART), 234 awareness method, 66, 234 teaching and counseling, 92–93 Assisted vaginal breech delivery, 182 Basal cell carcinoma (BCC), 316 visit information, 86–89 Association abnormalities, fetal, defined, BAT (brown adipose tissue), 136 Anthropoid pelvic type, 83, 165 102 Battery in tort law, defined, 349 Anthropometric measurements, 14, 29 Association of Women’s Health, Obstetrics Battledore placenta, 178 Antibiotics and Neonatal Nurses (AWHONN), BBT (basal body temperature) fertility acne, 314 338 awareness method, 66, 234 acute otitis media, 260–261 Asthma, 258–259t, 265–267 BCC (basal cell carcinoma), 316 chancroid, 220 Asymmetric growth restriction, 105, 149 Beneficence as ethical principle, 349 chlamydia, 214 Asynclitism vs synclitism, 168 Benign cystic teratoma, 206 conjunctivitis, 260 Ataractics, 169–170 Benign tumors, gynecological, 205–207 diarrhea caused by bacteria, 272 ATBD (active TB disease), 267, 268, 269 Benzodiazepines, 152, 319–320, 325 LGV, 221 Atherosclerosis, 254 Benzoyl peroxide, 313–314 pharyngitis, 263–264 Atonic seizure, 311, 312 Beta agonists, 179 PID, 222 Atresia, 227 Beta subunit radioimmunoassay, 47 pneumonia, 265 Attachment, infant–parent, 28, 139, 146, Beta-adrenergic blockers, 247, 248t, 255, syphilis, 219 186–187 299 TB, 269 Atypical glandular cells (AGC) on Pap test, Beta-adrenergic receptor agonists, 107 UTIs, 223 235, 236 Bethesda system for Pap test results, 235 Index 361

BHT (bioidentical hormone therapy), 45 screening recommendations, 23–24, 41, menopausal changes in, 42 Biguanides, 296t 43, 47, 118–119 newborn, 135, 148–149, 153 Bile acid sequestrants, 253 thelarche, 39 physical exam, 15–16 Biliary colic, 280 Breathing techniques during second stage, pregnancy changes in, 84 Bioidentical hormone therapy (BHT), 45 174 thromboembolic disease, 250–251 Biophysical profile (BPP), 95–96 Breech presentation, 108, 182–183 vascular disorders, secondary headache Birth control. See Fertility control Brown adipose tissue (BAT), 136 due to, 307, 309 Birth control pills. See Oral contraceptives BSE (breast self-examination), 23–24, 40 Carpal tunnel syndrome, 90 Birth defects or anomalies, 28, 101–102, Bulimia nervosa, 323–324 Catastrophic coverage, defined, 347 144, 152–155 Bulk-forming agents for constipation, 270 Causation in negligence tort, defined, Birth preferences consideration, 167 BUN (blood urea nitrogen) testing, 20 350 Birth rate, 86 Bupropion hydrochloride, 26–27 CBC (complete blood count), 19 Bisphosphonates, 304–305 Buspirone, 320 CCA (Continuing Competency Assessment) Blastocyst, 79 BV (bacterial vaginosis), 105, 211–212, 235 program, 341 Blastomeres, 79 CCBs (calcium channel blockers). See Bleeding C Calcium channel blockers (CCBs) DUB, 204 Caffeine category of drugs for headaches, CCNE (Commission on Collegiate Nursing postpartum hemorrhage, 177–178, 309, 311 Education), 338 184–185 CAGE screening tool for drinking problem, Central alpha adrenergic agonists, 249t during pregnancy, 99, 100–101 325 Central nervous system, anomalies testing for gastrointestinal, 22 Calcitonin-salmon for osteoporosis, 305 in newborns, 152–153. See also Blood. See Hematologic system Calcium antagonists, 249 Neurologic system Blood pressure, 24, 177, 245–247, 248–249t Calcium channel blockers (CCBs) Cephalagia (headaches), 90, 307–309, 311 Blood testing angina, 255 Cephalopelvic disproportion (CPD), 173, fecal occult blood, 22, 24 headache, 309 183 at onset of labor and delivery, 166 hypertension, 247, 249t Certification, 338, 339, 340, 341, 343–344 physical exam, 19–20 premature birth prevention, 107 Certified Nurse Midwife (CNM)/Certified type and Rh factor, 21, 116, 152 and premature labor, 180 Midwife (CM), 339 Blood urea nitrogen (BUN) testing, 20 Calcium nutritional requirements, 23 Certified Professional Midwife (CPM), 339 Blood-loss anemia, 117 Calendar fertility awareness method, 66 Certified registered nurse anesthetist BMD (bone mineral density) testing, 25, Cancers/carcinomas (CRNA), 338 50, 304 breast, 118, 226–227 Cervical cancer, 46, 119, 207 Body mass index (BMI), 14, 90 cervical, 46, 119, 207 Cervical cap, 63–64 Bonding, newborn–parent, 28, 139, 146, choriocarcinoma, 210–211 Cervical dysplasia, 235 186–187 as complications of pregnancy, 118–119 Cervical intraepithelial neoplasia (CIN), Bone integrity, 25, 42, 44, 50, 303–305 endometrial, 208 207, 235 Bone mineral density (BMD) testing, 25, hepatocellular, 277 Cervical polyps, 205 50, 304 HPV’s role in, 207, 214 Cervix Bottle-feeding, newborn care, 140, 186 ovarian, 208–209 anatomy and physiology of, 38, 42 BPP (biophysical profile), 95–96 skin, 14, 235, 236, 316–317 incompetent, 100–101 Brandt-Andrews maneuver, 177 vaginal, 209–210 physiologic adaptations in pregnancy, 83 Brazelton sleep-wake states for newborn, vulvar, 210 postpartum changes, 185 145 Candidiasis, vulvovaginal (VVC), 105, Chadwick’s sign, 83 BRCA1/BRCA2 genes, 24, 41, 208, 226 212–213, 235 Chancroid, 49, 220 Breach of duty in negligence tort, defined, Cannabis use, effects of, 152, 234 Chemotherapy during pregnancy, 118, 119 350 Capitation reimbursement system, 345, Chest circumference of newborn, 144 Breast cancer, 118, 226–227 346, 348 CHF (congestive heart failure) in Breast self-examination (BSE), 23–24, 40 Carbamazepine, 310t pregnancy, 120 Breastfeeding, 92, 139, 140, 186 Carboprost, 178 Chicken pox (herpes varicella), 26, 113–114 Breasts Carcinomas. See Cancers/carcinomas Chicken pox (varicella), 26, 93, 113 and aging, 29 Cardiff “Count to 10” fetal movement Child abuse or neglect, risk factors for, 28 anatomy and physiology of, 37 method, 95 Childbirth education, 92 biopsy as diagnostic tool, 48 Cardinal movements of labor, 172, 174 Chlamydia (CT) engorgement discomfort, 188 Cardiovascular system diagnosis, 214 fibrocystic changes, 224–225 CHD, 20–21, 251, 252 etiology/incidence, 213–214 galactorrhea, 203 coronary artery disease, 254–255 LGV, 220–221 menopausal changes, 42 dyslipidemia, 251–254 management/treatment, 214 physical exam, 17 fetal heart monitoring, 87, 95, 165–166, in newborns, 151 physiologic adaptations in pregnancy, 170–171, 173–174 during pregnancy, 104 83, 89 heart disease during pregnancy, 119–120 screening test for, 24, 48 postpartum changes, 185 heart murmurs, 247, 250 Choanal atresia, 153 postpartum checkup, 187 hypertension, 108–110, 245–247, Cholecystitis (gallstones), 280–281 during reproductive years, 39, 40 248–249t Choledocholithiasis, 280, 281 362 Index

Cholesterol problems (dyslipidemia), Condyloma acuminata (genital warts), 49, Cyanotic heart disease, 153 251–254 104, 214–215 Cystic changes in breast, defined, 224 Cholesterol testing, 20–21, 24, 43 Confidentiality, 350 Cystitis, 111, 222–223 Choriocarcinoma, 210–211 Congenital abnormalities in newborn, 141, Cystocele, 229 Chorion, 80 152–154 Cystourethrocele, 229 Chorion frondosum, 80 Congenital and chromosomal Cytomegalovirus (CMV), 151 Chorion laeve, 80 abnormalities, gynecological, Cytotrophoblast, 80 Chorionic villus biopsy (CVB), 94 227–228 Chorionic villus sampling (CVS), 94 Congenital syphilis, 103 D Chromosomes Congestive heart failure (CHF) in D (Rh) isoimmunization, 21, 88, 116–117, definitions and basics, 102 pregnancy, 120 152 gynecological abnormalities, 227–228 Conjunctivitis, 257, 260 Dacryocystitis in newborn, 147 newborn anomalies, 102, 154 Consent, 350 Damages in negligence tort, defined, 350 Chronic pelvic pain, 228–229 Constipation, 89, 188, 269–271 Dating of pregnancy, 82 CIN (cervical intraepithelial neoplasia), Consultation, defined, 345 DBP (diastolic blood pressure), 245 207, 235 Contact dermatitis, 315 D&E (dilation and evacuation) abortion Circulatory system. See Cardiovascular Content knowledge for test taking, 3–6, 4t method, 70 system Continuing Competency Assessment (CCA) Decidua basalis, 80 Circumcision of newborn, 146 program, 341 Decidua capsularias, 80 Circumvallate placenta, 178 Contraceptives. See Fertility control Decongestants, 256t, 257, 262 Cirrhosis, treatments that aggravate, 51, 53, Contraction patterns in stages of labor, 168 Deep vein thrombosis (DVT), 250–251 56, 57, 59, 277 Contraction stress test (CST), 95 Deformation, fetal, defined, 102 Civil Monetary Penalties (CMP), 351–352 Contraindications, drug, overview, 31. See DeLee mucous trap suctioning, 177 Claims made liability insurance, 342 also specific disorders/problems Deletion of chromosome portion, defined, Cleft lip and palate, 153 Copper-containing IUC, 57, 58–59 102 Climacteric, 41–46 Cordocentesis, 96 Delivery management, 174–177. See also Clindamycin, 212 Core Competencies for Basic Midwifery Intrapartum period Clinical nurse specialist (CNS), 338 Practice, 344 Demand feeding system, 140 Clinical pelvimetry, 87, 165 Coronary artery disease, 254–255 Dental screening recommendations, 25 Clitoris, 37, 39 Coronary heart disease (CHD), 20–21, 251, Depressant abuse, 325 Clonazepam, 310t 252 Depression, 42, 320–321 Cluster headache, 307, 308 Corpus luteum, 83, 206 Dermatologic system CM (Certified Midwife), 339 Corticosteroids acne, 313–315 CMP (Civil Monetary Penalties), 351–352 inhaled, 258t and aging, 29 CMV (cytomegalovirus) in newborn, 151 labor management, 107, 180 contact dermatitis, 315 CNM (Certified Nurse Midwife), 339 for respiratory disorders, 256t, 258t menopausal changes in, 42 CNS (clinical nurse specialist), 338 SLE, 291 newborn care, 140–141, 147–148 Cocaine, pregnancy and newborn effects, topical, 256t, 257, 315 physical exam, 14 100, 101, 152 Cough suppressants, 263 rash in pregnancy, 90 COCs (combination oral contraceptives), Coworker incompetence and ethical issues, skin cancers, 14, 235, 236, 316–317 43, 50–52 350 tinea, 317–318 Cognitive function, menopausal effects, 42 CPD (cephalopelvic disproportion), 173, Dermatophytes, 317 Coitus interruptus, 67 183 Dermoid ovarian cysts, 206 Colcoscopy, 46–47 CPM (Certified Professional Midwife), 339 DES (diethylstilbestrol) in utero, 231 Colic, infant, 148 Cradle cap, 147 Descent movement of labor, 174 Collaborative care management, 345 Cramming (studying), 5–6 Developmental milestones for newborn Colostrum, 83, 185 Creatinine testing, physical exam, 20 (first 6 weeks), 146 Combination injectable contraceptives, 54 Credentialing, 339, 341, 344 DEXA (dual-energy x-ray absorptiometry), Combination oral contraceptives (COCs), CRNA (certified registered nurse 304 43, 50–52 anesthetist), 338 Diabetes mellitus Commission on Collegiate Nursing Crying in newborn, 145 defined, 293 Education (CCNE), 338 CST (contraction stress test), 95 diagnosis, 294–295 Common cold, 262–263 Cultural competence for midwifery, 344 etiology/incidence, 293–294 Community-acquired pneumonia, 264–265 Cultural health history, 12 gestational, 88, 115–116, 293 Complete abortion, defined, 99 Cultural issues and hypertension medication, 247 Complete blood count (CBC), 19 family role in pregnancy, 91 management/treatment, 295, 296t, 297 Complete breech presentation, 108, 182 menstruation, 41 tests for, 20, 25 Complex partial seizure, 311, 312 Curve of Carus, 174, 177, 183 Diagnostic studies/lab tests. See also Comprehension thinking, 1 CVB (chorionic villus biopsy), 94 specific disorders/problems Computerized tests, considerations for, 8 CVS (chorionic villus sampling), 94 and aging, 29

Conceptus, defined, 79 Cyanocobalamin for B12 deficiency anemia, antepartum (pregnancy), 82, 87–88 Condoms, 61–62 285 health assessment and promotion, 19–22 Index 363

intrapartum, 164, 166–167 Ears/hearing, physical exam, 15, 29, 43. See Etonogestrel contraceptive implant, 56–57 newborn care, 142–145 also Eye, ear, nose, and throat Euploidy, defined, 102 postpartum, 187 Eating disorders, 323–324 Eustress vs distress, 318 women’s health, 46–50 EBP (evidence-based practice), 352 Evidence-based practice (EBP), 352 Diagonal conjugate, 87 EBV (Epstein-Barr virus), 264 Exercise recommendations, 23 Diaper dermatitis, 147 Eclampsia, 109, 110 Expectorants, 263 Diaphragm (contraception), 62–63 ECP (emergency contraception pill), 57–58 Expressed consent, 350 Diaphragmatic hernia, 153 Ectopic pregnancy, 100 Expulsive effort (pushing) during delivery, Diarrhea, 271–272 EDC/EDD/EDB (estimated date of 168, 173 Diastolic blood pressure (DBP), 245 confinement/delivery/birth), 82, 164 Exstrophy of the bladder, 154 Diet and nutrition, 22–23, 90–91, 115, 166, Edinburgh Postnatal Depression Scale, 186 Extension movement of labor, 174 187 EIA (enzyme immunoassay) test for HIV, External genitalia Dietary Guidelines for Americans, 22 111 anatomy and physiology of, 37, 39, 41, 48 Dilation and evacuation (D&E) abortion Electrocauterization, 68 disorders involving, 105, 210, 212–213, method, 70 ELISA (enzyme-linked immunosorbent 231–233, 235 Direct billing system, 345 assay), 47, 287 External hemorrhoids, 272 Direct entry midwife, 339 Embryo, 79, 81–82 External rotation movement of labor, 174 Direct maternal death, defined, 86 Emergency contraception, 57–58 External uterine monitoring of fetus, 172 Direct vasodilators, 247 Endocervical adenocarcinoma in situ (AIS), Eye, ear, nose, and throat Discharge planning, newborn care, 235, 236 acute otitis media, 260–261 140–142 Endocrine system. See also Diabetes allergic rhinitis, 255, 256t Discomforts mellitus common cold, 262–263 of postpartum period, 188 hyperthyroidism, 116, 298–300 conjunctivitis, 257, 260 of pregnancy, 89–90 hypoglycemia, 136, 297–298 IM, 264 Discovery rule, 350 hypothyroidism, 300–301 pharyngitis, 263–264 Disease-modifying antirheumatic drugs, menstrual disorders, 197–204 sinusitis, 261–262 292–293 postpartum changes, 186 Eye problems in newborn, 147 Disruption, fetal, defined, 102 pregnancy changes, 84 Eyes/sight, physical exam, 14, 29 Distress vs eustress, 318 thyroid function studies, 21, 25, 43 Ezetimibe, 253 Disulfiram, 325 Endometrial carcinoma, 208 Diuresis postpartum, 188 Endometrial hyperplasia, 44 F Diuretics for hypertension, 247, 248t Endometriosis, 202 Face presentation, 183 Dizygotic (DZ) multiples, 107, 183 Endometrium, biopsy as diagnostic tool, FACNM (Fellowship of the College), 341 Do Not Resuscitate Order (DNR), 350 47–48 Fallopian tubes, anatomy and physiology Doctor of Nursing Practice (DNP), 343 Engagement movement of labor, 174 of, 38 Domestic violence, 98–99, 321–322 Enterocele, 229 False imprisonment in tort law, defined, Dopamine agonists, 204 Enzyme immunoassay (EIA) test for HIV, 349 Doppler velocimetry blood flow 111 Family health history, 12, 164 assessment, 94 Enzyme-linked immunosorbent assay Family issues during pregnancy, 91–93 Doula, 339 (ELISA), 47, 287 Family planning. See Fertility control Down syndrome, 102, 154 Epilepsy, 310t, 311, 312 Fatigue in pregnancy, 89 Drug use and abuse. See Substance Episiotomy, 173, 175, 176 Fecal occult blood test recommendations, dependency and abuse Epispadias, 154 22, 24 Drug/medication considerations, 30–31, 93. Epithelial carcinoma, 208 Feeding patterns, newborn, 92, 139, 140, See also specific disorders/problems Epithelial cell abnormalities on Pap test, 186 Dual-energy x-ray absorptiometry (DEXA), 235, 236 Fee-for-service reimbursement system, 304 Epstein-Barr virus (EBV), 264 345, 348 DUB (dysfunctional uterine bleeding), 204 Erb’s palsy in newborns, 151 Fellowship of the College (FACNM), 341 Dubowitz scale, 143 Ergotamines, 309 Female condom, 62 Duncan mechanism for placental delivery, Erikson, Erik, 146 Female sterilization, 68 177 Escherichia coli infection, 150, 222 Ferrous sulfate for iron deficiency anemia, Duodenal vs gastric ulcers, 276 Esophageal atresia, 153 285 Duty in negligence tort, defined, 350 Estimated date of confinement/delivery/ Fertility awareness methods, 44, 65–66, 67 DVT (deep vein thrombosis), 250–251 birth (EDC/EDD/EDB), 82, 164 Fertility control. See also Oral Dysfunctional uterine bleeding (DUB), 204 Estradiol, 39, 49 contraceptives Dyslipidemia (cholesterol problems), Estriol, 39 abortion, 69–70 251–254 Estrogen, functions of, 38, 39, 44, 50–51 abstinence, 67–68 Dysmenorrhea, 198–199 Estrogen vaginal ring, 45 barrier methods, 61–65, 69, 187 DZ (dizygotic) multiples, 107, 183 Estrone, 39 coitus interruptus, 67 Ethical considerations, 98, 349–352 emergency contraception, 57–58 E Ethnicity and race status, intrapartum fertility awareness, 44, 65–66, 67 Ear infections, 260–261 considerations, 163 future methods, 69 364 Index

Fertility control (continued) Follicular phase of ovarian cycle, 40 Genitourinary system. See also for HIV patients, 288, 290 Footling (incomplete) breech presentation, Gynecological disorders injectable contraceptives, 54–56 108, 182 incontinence, 223–224 IUC, 43–44, 57, 58–61, 69, 187 Foreskin care, 146 menopausal changes in, 42 lactational amenorrhea, 67, 188 Formula feeding, 140, 186 newborn, 149, 154 postpartum considerations, 92–93, 187 4 Ps of labor, 168 pregnancy changes, 83–84, 90 progestin-only forms, 53, 55–57 Fracture risk algorithm (FRAX), 304 urinary tract disorders, 110–111, 222–224 spermicides, 61–64, 69, 187 Fractures, neonatal, 151–152 Genome, defined, 102 sterilization, 44, 68–69, 92–93 Framingham CHD risk tool, 252 Genotype, defined, 102 transdermal system, 53–54 Frank breech presentation, 108, 182 GERD (gastroesophageal reflux disease), vaginal ring, 54–55 FRAX (fracture risk algorithm), 304 281–282

women older than 40, 43 Free thyoxine (FT4), 21 German measles (rubella), 21, 26, 93, 113, Fertility rate, 86 Friedman’s stages of labor, 168, 169 151 Fertilization process, 79–80 FSE (fetal scalp electrode), 170, 172 Gestational age of newborn, 82, 143–144 Fetal alcohol syndrome, 152 FSH (follicle stimulating hormone), 39, 49 Gestational diabetes mellitus (GDM), 88, Fetal fibronectin (fFN) screening, 106 Fundal height, 87 115–116, 293 Fetal heart rate (FHR), 95, 165–166, Gestational trophoblastic disease, 210 170–171, 173–174 G GI (glycemic index), 298 Fetal heart tones, 87 GABHS (group A b-hemolytic GIFT (gamete intrafallopian transfer), 234 Fetal movement counting (FMC), 94–95 streptococcus) infection, 263, 264 Glandular cell abnormalities on Pap test, Fetal pulse oximetry, 172 Galactorrhea, 203–204 235, 236 Fetal scalp electrode (FSE), 170, 172 Galactosuria, 155 Glucose regulation in newborn during Fetal scalp sampling, 172 Gallstones (cholecystitis), 280–281 transition, 136 Fetal scalp stimulation, 172 Gamete intrafallopian transfer (GIFT), 234 Glucose testing, 20, 25, 43, 115 Fetus Gametogenesis, 79 Glycemic control for diabetes, 295 abnormalities in, 99, 101–102 Gastric vs duodenal ulcers, 276 Glycemic index (GI), 298 antepartum assessment, 93–96 Gastroesophageal reflux disease (GERD), GnRH agonists, 198, 202, 206 defined, 79 281–282 Gonadal dysgenesis, 228 development of, 81–82 Gastrointestinal system. See also Hepatitis Gonadotropin-releasing hormone (GnRH), labor and delivery role of, 168, 176 entries 38, 40, 80 stillbirth (fetal death), 86, 103 appendicitis, 275 Gonorrhea (GC), 48, 104, 150, 215–216, 263 well-being monitoring, 87, 95, 165–167, bleeding, testing for, 22 Goodell’s sign, 83 170–171, 173–174 cholecystitis, 280–281 Grand multipara, defined, 87 fFN (fetal fibronectin) screening, 106 constipation, 89, 188, 269–271 Granny, 339 FHR (fetal heart rate), 95, 165–166, 170–171, diarrhea, 271–272 Graves’ disease, 298, 299 173–174 GERD, 281–282 Gravida, defined, 12, 86 Fibric acid derivatives, 253 hemorrhoids, 272–273 Gravidity, 12, 163–164 Fibroadenoma, 225–226 IBS, 273–275 Grief process, 91–92, 187 Fibrocystic breast changes, 224–225 newborn, 137, 149, 153 Griseofulvin, 318 Fibroid tumors, 205–206 postpartum changes, 186 Group A b-hemolytic streptococcus Fibromyalgia, 305–306 pregnancy changes, 83 (GABHS) infection, 263, 264 Fibrous changes in breast, defined, 224 PUD, 276–277 Group B b-hemolytic streptococcus (GBS) Fidelity as ethical principle, 349 Gastroschisis, 154 infection, 150, 180 Fimbriectomy, 68 GBS (group B b-hemolytic streptococcus) GTPAL (gravida, term, preterm, abortion, First episode nonprimary, HSV, 217 infection, 150, 180 living) notation, 12 First reactivity period in newborn, 139 GC (gonorrhea), 48, 104, 150, 215–216, 263 “Gut closure” process for newborn, 137 First stage of labor, 168, 169–173 GDM (gestational diabetes mellitus), 88, Gynecoid pelvic type, 83, 165 First trimester 115–116, 293 Gynecological disorders. See also Sexually bleeding in, 99 General screening examination, 13–19 transmitted diseases/infections nausea and vomiting, 89 Generalized anxiety disorder, 319 (STDs/STIs) psychosocial changes, 85 Generalized seizures, 311, 312 abnormal Pap test, 235 Flexion movement of labor, 174 Genetic counseling, 102–103 amenorrhea, 67, 188, 199–200, 203 Fluconazole, 213 Genetic factors breasts, 118, 203, 224–227 Fluid balance alterations in newborn, 149 and abnormalities, 102–103, 154, chronic pelvic pain, 228–229 FMC (fetal movement counting), 94–95 227–228 congenital/chromosomal abnormalities, Foam stability test for fetal lung maturity, BRCA1/BRCA2 genes, 24, 41, 208, 226 227–228 96 inherited anemias, 118 DES in utero, 231 Folic acid, 23, 117 Genital herpes simplex. See Herpes simplex DUB, 204 Folic acid deficiency anemia, 283, 284, 285, virus (HSV) infertility, 233–235 286 Genital warts, 49, 104, 214–215 menstrual, 197–204 Follicle stimulating hormone (FSH), 39, 49 Genitalia, anatomy and physiology of, 37. tumors/neoplasms, 46, 119, 205–211, 214 Follicular ovarian cysts, 206 See also specific organs urinary tract disorders, 110–111, 222–224 Index 365

vaginal infections, 105, 211–213, 235 Hegar’s sign, 83 in newborns, 151 vestibulitis, 233 Helicobactor pylori, 276, 277 during pregnancy, 111–113 vulvar dermatoses, 231–233 HELLP syndrome, 109, 110 risk assessment, 12 vulvodynia, 233 Hematocrit (Hct)/hemoglobin (Hgb) screening for, 21, 49 Gynecology (normal). See also Fertility testing, 19 HMO (Health Maintenance Organization), control Hematologic system. See also Blood testing 346 diagnostic studies/lab tests, 46–50 anemias, 117–118, 282–286 (See also Hormonal contraceptives, 43, 50–58, 69, menopause, 41–46 Sickle cell anemia (SS disease)) 187, 221 puberty/adolescence, 38–39 blood glucose testing, 20, 25, 43, 115 Hormone therapy (HT), 44–45, 199, 202, reproductive organs, 37–38 blood incompatibilities, 21, 116–117, 152 204, 304 reproductive years, 39–41 newborn, 136–137 Hormones. See also specific hormones postpartum changes, 185 normal reproductive role of, 39–40 H pregnancy changes, 84 produced by trophoblast in utero, 80

H2-receptor antagonists, 282 Hemoglobinopathies, 118, 282 testing for serum hormone levels, 49 HAART (highly active antiretroviral Hemolytic disease, 116–117, 152, 282 Hot flashes (vasomotor symptoms) of therapy), 112 Hemorrhage, postpartum, 177–178, 184–185 menopause, 42, 44, 46 Habitual abortion, defined, 99 Hemorrhoids, 89, 188, 272–273 HPV (human papillomavirus). See Human Haemophilis ducreyi (chancroid), 220 Hepatitis A virus (HAV), 26, 277–278, 279t, papillomavirus (HPV) Haploid number of chromosomes, 79 280 HSIL (high-grade squamous intraepithelial Hashimoto’s thyroiditis, 300 Hepatitis B virus (HBV) lesion), 235, 236 HAV (hepatitis A virus), 26, 277–278, 279t, diagnosis, 278, 279t HSV (herpes simplex virus). See Herpes 280 etiology/incidence, 277 simplex virus (HSV) HBV (hepatitis B virus). See Hepatitis B and hepatitis D, 278 HT (hormone therapy), 44–45, 199, 202, virus (HBV) immunization recommendations, 25 204, 304 hCG (human chorionic gonadotropin), 47, management/treatment, 278, 280 Huhner’s test, 234 80, 99 in newborn, 151 Human chorionic gonadotropin (hCG), 47, HCV (hepatitis C virus), 277–278, 279t, 280 screening test for, 21, 49 80, 99 HDL (high-density lipoproteins), 251 vaccination for, 93, 140 Human immunodeficiency virus (HIV). HDV (hepatitis D virus), 278, 279t, 280 Hepatitis C virus (HCV), 277–278, 279t, 280 See HIV (human immunodeficiency Head and neck, general health, 14, 29 Hepatitis D virus (HDV), 278, 279t, 280 virus) Head circumference of newborn, 144 Hepatitis E virus (HEV), 278, 279t Human papillomavirus (HPV) Headaches, 90, 307–309, 310t, 311 Hepatocellular carcinoma and hepatitis C, and cervical cancer, 207 Health assessment and promotion 277 and Condyloma acuminata, 214 aging considerations, 29–30 Herniated intervertebral disc, 301 immunization recommendations, 26 childbirth education, 92 Heroin, obstetrical complications from, 97 during pregnancy, 104 genetic counseling, 102–103 Herpes simplex virus (HSV) screening test for, 49 health history, 11–13 diagnosis, 217 and vulvar cancer, 210 health maintenance, 22–28 etiology/incidence, 216–217 Hydatidiform mole, 100 intrapartum period, 163–164 management/treatment, 217–218 Hydrocephalus, 153 menopause, 43 in newborn, 151 Hydroxychloroquine, 291 nongynecological tests, 19–22 Pap test predictiveness, 236 Hyperandrogenism, 201 parenting, 28–29 during pregnancy, 103–104 Hyperbilirubinemia, 140, 141–142, 147, 152 pharmacology, 30–31 screening test for, 48–49 Hyperglycemia. See Diabetes mellitus physical examination, 13–19 types, 216 Hyperosmolar laxatives, 270–271 physiology of pregnancy, 83 Herpes varicella-zoster virus (VZV), 26, Hyperplasia in breast, defined, 224 preconception care, 28 113–114 Hyperprolactinemia, 203–204 risk factor identification, 22–28 HEV (hepatitis E virus), 278, 279t Hypertension, 108–110, 245–247, 248–249t Health history, 11–13, 137 High-density lipoproteins (HDL), 251 Hyperthyroidism (thyrotoxicosis), 116, Health Insurance Portability and High-grade squamous intraepithelial lesion 298–300 Accountability Act (HIPAA) (1996), (HSIL), 235, 236 Hypoglycemia, 136, 297–298 350–352 Highly active antiretroviral therapy Hypoglycemic agents, oral, 295, 296t, 297 Health Maintenance Organization (HMO), (HAART), 288 Hypomenorrhea, 204 346 Hip dysplasia, congenital, 154 Hypoplasia, 227 Health Maintenance Organization (HMO) HIPAA (Health Insurance Portability and Hypospadias, 154 Act (1973), 346 Accountability Act (1996)), 350–352 Hypothyroidism, 300–301 Healthcare delivery systems, 345–349 Histamine receptor antagonists, 276–277 Hysterosalpingogram, 234 Healthy People 2010 initiative, 341–342 HIV (human immunodeficiency virus) Hysteroscopy, 234 Hearing, physical exam, 15, 29, 43 chancroid association, 220 Heart disease, 20–21, 119–120, 247, 251, defined, 286 I 252. See also Cardiovascular system diagnosis, 111–112, 287–288 IBS (irritable bowel syndrome), 273–275 Heart murmurs, 247, 250 etiology/incidence, 286–287 ICM (International Confederation of Heartburn, 89, 281–282 management/treatment, 288, 289t, 290 Midwives), 344 366 Index

IDM (infants of diabetic mothers), 150 Inhaled short acting B2-agonists, 258t Involution of uterus, postpartum, 185, 188 IFA (immunofluorescence assay) test for Inherited anemias, 118 Iron deficiency anemia, 117, 283, 284–285, HIV, 112 Injectable contraceptives, 54–56 286 IFG (impaired fasting glucose), 293–294 Insomnia during pregnancy, 90 Iron requirements (nonpregnant women), IGT (impaired glucose tolerance), 293–294 Inspection technique of examination, 13 23 Illegal drug use, 97, 100, 101, 152, 234 Insulin replacement therapy, 295 Irritable bowel syndrome (IBS), 273–275 IM (infectious mononucleosis), 264 Insurance, malpractice, 342 Irritant contact dermatitis, 315 Imaging memory aid, 3 Integrated delivery systems (MCOs), 345, Irving procedure, 68 Immune system, newborn’s, 137 346–349 Ischemic heart disease, 247 Immunization recommendations Integumentary changes during pregnancy, Ischial spines, 87 hepatitis B, 25, 93, 140, 278, 280 84 Isochromosome, defined, 102 newborn care, 140 Intentional infliction of emotional distress Isotretinoin, 314, 315 postpartum, 187 in tort law, defined, 349–350 Itraconazole, 318 pregnancy considerations, 93 Intentional tort, defined, 349 IUC (intrauterine contraception), 43–44, 57, routine, 25–26, 30 Interactions among drugs, defined, 31. See 58–61, 69, 187 TB, 114 also specific disorders/problems IUGR (intrauterine growth restriction), varicella-zoster (VZV), 114 Intermittent asthma, 266, 267 105–106, 178 Immunocontraceptives, 69 Internal hemorrhoids, 272 IUPC (intrauterine pressure catheter), 168 Immunofluorescence assay (IFA) test for Internal rotation movement of labor, 174 IVF (in vitro fertilization), 234 HIV, 112 International Confederation of Midwives Immunologic disorders. See also HIV (ICM), 344 J (human immunodeficiency virus) International midwifery, 344 Jarisch-Herxheimer reaction, 103 Graves’ disease, 298, 299 Interspinous diameter, 87 Jaundice, 140, 141–142, 147, 152 Hashimoto’s thyroiditis, 300 Interstitial leiomyomata uteri, 205 Justice as ethical principle, 349 rheumatoid arthritis, 291–293 Intertuberous diameter, 87 SLE, 290–291 Intimate partner abuse, 98–99, 321–322 K and vulvar dermatoses, 232 Intimate partner violence, 98–99, 321–323 Kenicterus in newborn, 152 Immunosuppressed individuals, abnormal Intra-articular injection for osteoarthritis, Kidneys. See Renal system Pap test handling, 236 303 Knee presentation, 182 Impaired fasting glucose (IFG)/impaired Intraductal papilloma, 226 glucose tolerance (IGT), 293–294 Intraligamentous leiomyomata uteri, 205 L Implantation of blastocyst, 79–80 Intrapartum period Lab tests. See Diagnostic studies/lab tests Implants, progestin-only, 56–57 breech presentation, 108, 182–183 Labia majora, 37, 39 Implied consent, 350 cardinal movements of labor, 174 Labia minora, 37 In vitro fertilization (IVF), 234 delivery management, 174–177 Labor and delivery phase. See Intrapartum Inborn errors of metabolism, 102, 154–155 diagnostic studies/lab tests, 164, 166–167 period “Incident to” services, Medicare face presentation, 183 LACE (Licensure, Accreditation, reimbursement for, 348 first stage of labor, 169–173 Certification, and Education) model, Incompetent cervix, 100–101 initial assessment, 163–164 343 Incomplete abortion, 99, 100 management and teaching, 166 Lactational amenorrhea, 67, 188 Incomplete (footling) breech presentation, mechanisms of labor, 168 Lactobacilli, BV and loss of, 211 108, 182 newborn transition overview, 178 Laparoscopy, 49 Incontinence, urinary, 223–224 physical exam, 164–166 Large for gestational age (LGA), 106, 149 Independent and collaborative care placenta previa, 101, 181 Latent labor, defined, 168 management, 345 placental abruption, 101, 181 Latent TB infection (LTBI), 267, 268–269 Indirect billing system, 345 placental delivery, 177–178 Law, defined, 349. See also Legal and ethical Inevitable abortion, 99 postpartum hemorrhage, 177–178, issues Infant development, educational overview, 184–185 LBP (low back pain), 301–302 28–29. See also Newborn care premature labor situation, 178–180 LDL (low-density lipoproteins), 251 Infant mortality rate, defined, 86 retained placenta, 184 Learning principles for women/families Infants of diabetic mothers (IDM), 150 second stage of labor, 168, 173–174 during pregnancy, 92–93 Infection. See also specific disorders/ shoulder dystocia, 181–182 Lea’s shield, 64–65 problems twin gestation delivery, 183–184 Lecithin/sphingomyelin ratios (L/S), 96 control of during physical exam, 18–19 umbilical cord prolapse, 180 Leg cramps during pregnancy, 89 neonatal, 41, 150 Intrauterine contraception (IUC), 43–44, Legal and ethical issues Infectious disease screening, 21–22. See also 57, 58–61, 69, 187 consensus model for midwifery specific disorders/problems Intrauterine growth restriction (IUGR), regulation, 343 Infectious mononucleosis (IM), 264 105–106, 178 coworker incompetence issue, 350 Infertility, 233–235 Intrauterine infection in newborn, 150 and drug use/abuse, 98 Influenza vaccine recommendations, 25, 93 Intrauterine pressure catheter (IUPC), 168 ethical principles, 349 Informed consent, 350 Intravenous access methods, intrapartum, HIPAA, 350–352 Inhaled corticosteroids, 258t 166 law making definitions, 346 Index 367

liabilities and concerns, 342, 349–350 Luteinizing hormone, 39, 49 Meglitinides, 296t regulatory action, nature of, 346 Lymphogranuloma venereum (LGV), Meiosis, 79 rights of patients, 350–351 220–221 Membranes, uterine, 80, 107, 165, 167, 179 and scope of practice, 342 Memory and test taking, 1, 2–3, 6–7 Leiomyomata uteri, 205–206 M Mendelian (single-gene) disorders, 102 Length of newborn, assessment of, 144 Macrocytic anemia, 282 Meningocele/myelomeningocele, 152–153 Leopold’s maneuvers, 87, 108 Macrosemia (LGA babies), 106, 149 Meningococcal disease, immunization for,

Leukorrhea during pregnancy, 90 Magnesium sulfate (MG SO4), 107, 179–180 26 Leukotriene modifiers, 259t Male condom, 61–62 Menopause, 41–46 Levonorgestrel as emergency contraceptive, Male factor leading to infertility, 233–234 Menorrhagia, 204 58 Male hormonal contraceptives, 69 Menstrual history, 12 Levonorgestrel contraceptive implant, Malformation, fetal, defined, 101 Menstruation 57 Malignant melanoma (MM), 14, 119, disorders of, 197–204 Levonorgestrel Intrauterine System (LNG 316–317 estrogen’s role in, 39 IUS), 58–59 Malpractice, defined, 349 initiation of, 39 Levothyroxine, 300 Malpractice insurance, 342 menopausal changes, 41 LGA (large for gestational age), 106, 149 Malpresentations, 108 normal menstrual cycle, 40 LGV (lymphogranuloma venereum), Mammography, 24, 41, 43, 47, 118–119 postpartum resumption of, 186 220–221 Managed care organizations (MCOs), 345, psychosocial/cultural factors, 41 Liabilities and concerns, 342, 349–350 346–349 Mental status, physical exam, 17 Licensed midwife (LM), 339 Marijuana use, effects of, 152, 234 Metabolic system. See also Endocrine Licensure, 344 Mast cell stabilizers, 256t, 257, 259t system Licensure, Accreditation, Certification, and Maternal morbidity, defined, 86 changes during pregnancy, 85 Education (LACE) model, 343 Maternal mortality ratio, defined, 86 danger signs in newborn, 149 Lichens planus, 231–232 Mauriceau-Smellie-Veit maneuver, 183 newborn anomalies, 154–155 Lichens sclerosus, 231–232 McBurney’s point, 275 newborn assessment, 145 Lichens simplex chronicus, 231, 232 MCOs (managed care organizations), 345, secondary headache due to disorders Links as memory aid, 3 346–349 of, 307 Lipid profile, physical exam, 20–21, 24, 43 MCQs (multiple-choice questions), Methylergonovine, 177–178 Listeria infection in newborn, 150 preparing for, 6–7, 7t Methylxanthines, 259t Live birth, defined, 86 McRobert’s maneuver, 182 Metronidazole, 105, 211, 212, 222 Liver function/disorders. See also Hepatitis Mean corpuscular hemoglobin (MCH), 19 Metrorrahgia, 204 entries Mean corpuscular hemoglobin Microcytic anemia, 282 cirrhosis, 51, 53, 56, 57, 59, 277 concentration (MCHC), 19 Midwifery diagnostic studies, 22 Mean corpuscular volume (MCV), 19 ACNM, 340–341, 343 hyperbilirubinemia, 140, 141–142, 147, Meconium aspiration, 138–139 certification, 341 152 Median episiotomy, 175 consensus model for regulation, 343 and macrocytic anemia, 282 Medicaid, 348–349 Core Competencies for Basic Midwifery LM (licensed midwife), 339 Medical complications, newborn care, 41, Practice, 344 LNG IUS (Levonorgestrel Intrauterine 102, 141, 148–155 credentialing, 344 System), 58–59 Medical complications during pregnancy cultural competence, 344 Lobes, breast, defined, 37 acquired anemias, 117 DNP, 343 Lobules, breast, defined, 37 appendicitis, 118 Healthy People 2010 initiative, 341–342 Local anesthesia, 167, 174 blood incompatibilities, 116–117 history of, 339–340 Lochia (discharge), postpartum, 185 diabetes, 88, 115–116, 293 independent and collaborative care

Long acting inhaled B2-agonists, 258t heart disease, 119–120 management, 345 Long acting nitrates for angina, 255 HIV/AIDS, 111–113 international, 344 Loop diuretics, 248t inherited anemias, 118 legislative and regulatory policy, 346 Low back pain (LBP), 301–302 neoplastic disease/cancers, 118–119 liability insurance, 342 Low-density lipoproteins (LDL), 251 rubella, 113 practice issues, 344 Lower respiratory disorders, 264–269 thyroid disease, 116 prescriptive authority, 344–345 Low-grade squamous intraepithelial lesion toxoplasmosis, 113 primary care role, 342, 343–344 (LSIL), 235, 236 tuberculosis, 114–115 privileging, 344 L/S (lecithin/sphingomyelin ratios), 96 urinary tract infections, 110–111 professional organizations, 345 LTBI (latent TB infection), 267, 268–269 varicella-zoster, 113–114 reimbursement issues, 345 Lubiprostone for IBS treatment, 275 Medicare, 347–348 scope of practice, 342 Lumbosacral strain (LBP), 301–302 Medicare+Choice, 347 standards of practice, 343 Lumpke’s paralysis in newborns, 151 Medication abortion, 69–70 Migraine headaches, 307, 308, 309 Lung maturity of fetus, assessment of, 96 Medication considerations, 30–31, 93. See Mild persistent asthma, 266, 267 Lupus (systemic lupus erythematosus), also specific disorders/problems Miscarriage, 60, 99–101 290–291 Mediolateral episiotomy, 175 Missed abortion, defined, 99 Luteal phase of ovarian cycle, 40 Megaloblastic anemia, 117 Mitosis, 79 368 Index

MM (malignant melanoma), 14, 119, Neonatal mortality rate, defined, 86 hematologic system, 117–118, 282–286 316–317 Neonatal period, defined, 86. See also (See also Sickle cell anemia Moderate persistent asthma, 266, 267 Newborn care (SS disease)) Molluscom contagiosum, 218 Neonatal reflexes, 144–145 musculoskeletal system, 25, 29, 44, Monozygotic (MZ) multiples, 107, 183 Neonatal resuscitation, 138 301–307 Mons pubis, 37, 39 Neoplastic disease. See Cancers/ neurologic system, 307–309, 310t, Montelukast, 257, 259t carcinomas 311–313 Montgomery’s glands, 37 Neural tube defects, 152–153 psychosocial problems, 42, 318–325 MORAL model of ethical decision making, Neuroglycopenia hypoglycemia, 297 respiratory system, 256t, 258–259t, 349 Neurologic system 262–269 “Morning-after pill,” 57–58 and aging, 29 Nongynecological tests, 19–22 Moro newborn reflex, 144–145 danger signs in newborn, 148 Nonmaleficence as ethical principle, 349 Morula, 79 headaches, 307–309, 311 Nonneoplastic epithelial disorders, 231 Motivation, test-taking, 8–9 neural tube defects, 152–153 Nonnucleoside reverse transcriptase Müllerian abnormalities, 227 newborn examination, 144 inhibitors (NNRTIs), 288, 289t Multigravida, defined, 86 physical exam, 16 Nonnutritive sucking, 146–147 Multipara, defined, 87 seizure disorders, 310t, 311–313 Nonsteroidal anti-inflammatory drugs. Multiple gestation, 107–108, 183–184 Neurosyphilis, 219 See NSAIDs (nonsteroidal anti- Multiple marker screen, 88 Newborn care inflammatory drugs) Multiple-choice questions (MCQs), assessment prior to discharge, 142–145 Nonstress testing (NST) of fetus, 95 preparing for, 6–7, 7t bonding with parent, 28, 139, 146, Nonvascular intracranial disorders, Murphy’s sign, 281 186–187 headache due to, 307 Muscle relaxants for LBP treatment, 302 common variations from normal Normocytic anemia, 282. See also Sickle cell Musculoskeletal system findings, 147–148 anemia (SS disease) and aging, 29 discharge planning, 140–142 North American Registry of Midwives fibromyalgia, 305–306 feeding patterns, 92, 139, 140, 186 (NARM), 339 low back pain, 301–302 first 6 weeks, 145–147 Nose and sinuses, 15, 29. See also Eye, ear, newborn anomalies, 154 in first few days of life, 140 nose, and throat osteoarthritis, 302–303 in first hours after birth, 139 NP (nurse practitioner) osteoporosis, 25, 44, 303–305 gestational age of newborn, 82, 143–144 certification, 338 physical exam, 16 immediate care and assessment, consensus model for regulation, 343 during pregnancy, 84 137–139 defined, 337 strains/sprains, 306–307 medical complications, 41, 102, 141, DNP, 343 Music as memory aid, 3 148–155 educational requirements, 338 Myelomeningocele/meningocele, substance abuse effects, 97–98, 100, 101, functions of, 337 152–153 105, 141, 152 Healthy People 2010 initiative, 341–342 Myoclonic seizure, 311, 312 transition to extrauterine life, 135–137, historical development, 337 Myomas, 205–206 139, 178 legislative and regulatory policy, 346 MZ (monozygotic) multiples, 107, 183 Nicotine addiction, 26–27, 97, 99, 101, 234 liability insurance, 342 Nicotine replacement therapy, 26 nurse practice acts, 343 N Nicotinic acid drugs, 253 primary health care and healthcare Naegele’s rule for pregnancy dating, 82 Nifedipine. See Calcium channel blockers reform, 342 Naltrexone, 325 (CCBs) roles of, 337 NARM (North American Registry of Nipples, breast, 37 scope of practice, 342 Midwives), 339 Nitroglycerine, sublingual, 255 standards of practice, 343 Nasal corticosteroids, 256t NLNAC (National League for Nursing NPI (National Provider Identifier) number, National Association of Nurse Practitioners Accrediting Commission), 338 348 in Women’s Health (NPWH), 338 NNRTIs (nonnucleoside reverse NPWH (National Association of Nurse National League for Nursing Accrediting transcriptase inhibitors), 288, 289t Practitioners in Women’s Health), Commission (NLNAC), 338 Nongestational trophoblastic disease, 210 338 National Provider Identifier (NPI) number, Nongynecological disorders/problems. NRTIs (nucleoside reverse transcriptase 348 See also Endocrine system; inhibitors), 288, 289t Nausea and vomiting of pregnancy, 89 Immunologic disorders; Medical NSAIDs (nonsteroidal anti-inflammatory Negligence, defined, 349 complications during pregnancy drugs) Negligence tort, 350 cardiovascular system, 20–21, 119–120, acute otitis media, 261 Neisseria gonorrhoeae, 48, 104, 150, 245–247, 248–249t, 250–255 DUB, 204 215–216, 263 dermatologic, 14, 235, 236, 313–318 dysmenorrhea, 199 Neonatal death, defined, 86 eye, ear, nose, and throat, 255, 256t, 257, endometriosis, 202 Neonatal fractures, 151–152 258–259t, 260–264 PUD, 276 Neonatal morbidity, danger signs of, gastrointestinal system, 89, 188, 269–278, rheumatoid arthritis, 292 148–149 279t, 280–282 SLE, 291 Index 369

NST (nonstress testing) of fetus, 95 Opiate abuse, 97, 152 PCP (primary care provider), MCO role of, Nuchal cord, dealing with, 176 Oral contraceptives 346 Nucleic acid testing for HIV, 112, 288 as anti-acne medication, 314 PE (pulmonary embolus), 250, 252 Nucleoside reverse transcriptase inhibitors COCs, 43, 50–52 Pediatric follow-up care, arranging, 142 (NRTIs), 288, 289t ECP, 57–58 Pedunculated leiomyomata uteri, 205 Nucleotide reverse transcriptase inhibitors, and fibrocystic breast changes, 225 Pelvic examination, 17–18, 87, 165, 166 288, 289t male pill, 69 Pelvic inflammatory disease (PID), 60, Nulligravida, defined, 86 POP, 53 221–222 Nullipara, defined, 86 postpartum considerations, 187 Pelvis and pelvic abnormalities/pathologies Nurse practice acts, 343 and SLE, 291 chronic pelvic pain, 228–229 Nurse practitioner (NP). See NP (nurse Oral hypoglycemic agents, 295, 296t, 297 CPD, 173, 183 practitioner) Oral steroids, 258t and infertility, 233 Nutrition, 22–23, 90–91, 115, 166, 187 Organization, importance in study maintaining integrity during delivery, preparation, 4–5 174–175 O Osteoarthritis, 302–303 musculature of, 37–38 OA (occiput anterior) position, 172, 176 Osteopenia, 304 PID, 60, 221–222 OBRA (Omnibus Budget Reconciliation Act) Osteoporosis, 25, 44, 303–305 relaxation of muscles in, 229–230 (1989), 348–349 Outpatient vs admission management structures, 37–38, 39, 83, 165 Obsessive-compulsive disorder (OCD), 319 decision, 166 Peptic ulcer disease (PUD), 276–277 Obstetrical complications Ovarian carcinoma, 208–209 Per member per month (PMPM) costs, 345, birth defects or anomalies, 28, 101–102, Ovarian cycle, 40 346 144, 152–155 Ovarian cysts, 201, 206–207 Percentage reimbursement system, 345 bleeding problems, 99–101 Ovaries, anatomy and physiology of, 38, 39, Percussion technique of examination, 13 ectopic pregnancy, 100 42, 83 Percutaneous umbilical blood sampling genetic abnormalities, 102–103, 154, Ovulation, 40 (PUBS), 96 227–228 Ovulation fertility awareness method, 66 Perennial vs seasonal allergies, 255 and gravidity/parity status, 163–164 Ovulatory dysfunction leading to infertility, Perimenopause, 41, 200, 204, 226 hydatidiform mole, 100 233 Perinatal mortality rate, defined, 86 hypertensive disorders, 108–110 Oxytocin, 107, 177 Perinatal period, defined, 86. See also intimate partner abuse/VAW, 98–99 Oxytocin challenge test (OCT), 95 Newborn care LGA/macrosemia, 106, 149 Perineum malpresentations, 108 P episiotomy decision during delivery, multiple gestation, 107–108, 183–184 PAC (political action committee) for ACNM, 173 placental anomalies, 101, 178, 181 341, 343 muscles of, 37–38, 174–175 postterm pregnancy, 86, 110, 149 Pacifier usage, 146–147 postpartum changes, 185 preterm birth, 86, 106–107, 108, 141, 149 Pain management postpartum checkup, 187 SGA/IUGR, 105–106, 178 headaches, 309, 310t, 311 postpartum discomfort, 188 spontaneous abortion, 60, 99–101 during labor and delivery, 167, 169–170, repairing lacerations in, 175–176 STIs, 103–105 173, 174 Peripheral blood smear, 20 substance abuse, 96–98 LBP, 302 Peripheral nervous system. See Neurologic Obstetrical history, 12 PAINS warning signs for IUC problems, 61 system Obstructed lacrimal ducts in newborn, 147 Palmar grasp, newborn reflex, 144 Peritoneal oocyte and sperm transfer Obturator sign, 275 Palpation technique of examination, 13–14 (POST), 234–235 Occiput anterior (OA) position, 172, 176 Pancreatitis, 280 PERRLA (pupils equal, round, react to light Occiput posterior (OP) position, 172–173 Panic disorder, 319 and accommodate), 14 Occurrence liability insurance, 342 Pap test, 24, 43, 46, 60–61, 235–236 PG (phosphatidylglycerol) fetal lung OCD (obsessive-compulsive disorder), 319 Para, defined, 86 maturity test, 96 OCT (oxytocin challenge test), 95 Parenting education, 28–29 Pharmacodynamics, 30 Office for Civil Rights (OCR), 351 Parity, 12, 87, 163–164 Pharmacokinetics, 30 OLDCARTS mnemonic for health history, Part A of Medicare, 347 Pharmacologic considerations, 30–31, 93. 11 Part B of Medicare, 347 See also specific disorders/problems Oligohydramnios, 81 Part C of Medicare—Medicare+Choice, 347 Pharyngitis, 263–264 Oligomenorrhea, 200–201, 204 Part D of Medicare (prescription drug Phenotype, defined, 102 Oligo-ovulation, 201 coverage), 347 Phenylketonuria, 154 Omnibus Budget Reconciliation Act (OBRA) Partial seizures, 311, 312 Phenytoin, 310t (1989), 348–349 Partographs of labor curve, 169 PHI (Protected Health Information), Omphalocele, 153–154 Passage principle in labor, 168 350–351 One-best-answer question types, 7 Passenger in labor, 168 Phosphatidylglycerol (PG) fetal lung One-letter memory aid, 3 Patent urachus, 154 maturity test, 96 Oogenesis, 79 Paternalism as ethical principle, 349 Phototherapy for jaundice, 152 OP (occiput posterior) position, 172–173 PCOS (polycystic ovarian syndrome), 201 Physical activity recommendations, 23 370 Index

Physical examination PPIs (proton pump inhibitors), 277, 282 Progestin in birth control pills, 50, 52 general health, 13–19, 29, 43 PPO (Preferred Provider Organization), Progestin-only hormone therapy for at labor and delivery, 164–166 346–347 menopause, 45 lipid profile, 20–21, 24, 43 Practice tests, 3, 7 Progestin-only implants, 56–57 newborn care, 137–139, 142–145 Preconception care, 28 Progestin-only injectable contraception, pelvic, 17–18, 87, 165, 166 Preeclampsia, 108–110 55–56 Physician’s role in labor and delivery, 167 Preferred Provider Organization (PPO), Progestin-only pills (POP), 43, 53 Physiologic adaptations during pregnancy, 346–347 Prolactin, 39 82–85, 89 Pregabalin, 306 Proliferative phase of uterine cycle, 40 PID (pelvic inflammatory disease), 60, Pregnancy. See also Antepartum care Proof liability, 350 221–222 abnormal Pap test handling, 236 Prophylactic therapy for migraines, 309 PIs (protease inhibitors), 288, 289t categories for drug contraindications, 31 Prospective pricing reimbursement Pituitary adenoma, 203–204 chlamydia’s risks to, 213 (capitation), 345, 346, 348 Placenta, 80–81, 101, 177–178, 181 diagnosis and dating, 82 Prostaglandin, 39 Placenta accreta, 184 discomforts and remedies, 89–90 Prostaglandin inhibitors, 107 Placenta increta, 184 embryonic and fetal development, 81–82 Prostaglandin synthetase inhibitors, 199 Placenta percreta, 184 family support role, 91–93 Protease inhibitors (PIs), 288, 289t Placenta previa, 101, 181 fertilization process, 79–80 Protected Health Information (PHI), Placental abruption, 101, 181 fetal health assessment techniques, 350–351 Placing and stepping, newborn reflex, 145 93–96 Proton pump inhibitors (PPIs), 277, 282 Plasma glucose testing, 25 immunization recommendations, 26, 93 Psoas sign, 275 Platelet count, 20 learning principles for counseling, 92–93 Psyche principle in labor, 168 Platypelloid pelvic type, 83, 165 medical complications, 110–120 Psychosis, postpartum, 186 Plexus injuries in newborns, 151 obstetrical complications, 96–110 Psychosocial issues. See also Substance PLISSIT model, 27 pharmacologic considerations, 93 dependency and abuse PMDD (premenstrual dysphoric disorder), physiologic adaptations, maternal, 82–85 anxiety, 318–320 198 psychosocial changes, 85–86, 91–93 attachment, infant–parent, 28, 139, 146, PMPM (per member per month) costs, 345, and SLE, 291 186–187 346 symptoms of, 82 and chronic pelvic pain, 229 PMS (premenstrual syndrome), 197–198 testing for, 47 circumcision, 146 Pneumococcus, immunization uterine environment for, 80–81 cultural factors in diet, 91 recommendations, 25–26 Premature labor situation, 178–180. See also cultural health history, 12 Pneumonia, 141, 264–265 Preterm birth depression, 42, 320–321 Point of Service Plan (POS), 347 Premature menopause, 41 discharge of newborn considerations, Political action committee (PAC) for ACNM, Premature rupture of membranes, 107, 179 141 341, 343 Premenstrual dysphoric disorder (PMDD), eating disorders, 323–324 Polycystic ovarian syndrome (PCOS), 201 198 intimate partner violence/VAW, 98–99, Polyhydramnios, 81 Premenstrual syndrome (PMS), 197–198 321–322 Polymenorrhea, 204 Prenatal period, risk factors, 88–89. See also during labor and delivery, 173, 174 Polyploidy, defined, 102 Pregnancy and labor management, 169 Pomeroy procedure, 68 Prescription drug abuse, effect on menopause, 42 POP (progestin-only pills), 43, 53 newborns, 152 and newborn assessment, 137–138 POS (Point of Service Plan), 347 Prescription drug coverage in Medicare newborn’s psychological tasks, 146 Position of fetus at delivery, 165, 172–173, (Part D), 347 nonnutritive sucking, 146–147 176 Prescriptive authority, 344–345 in PMS, 197 Positive thinking for testing motivation, 8–9 Presentation, fetal, 108, 165, 174–175, postpartum checkup, 187 POST (peritoneal oocyte and sperm 182–183 during pregnancy, 85–86, 91–93 transfer), 234–235 Presyncopal episodes, 89 at puberty, 39 Postcoital testing for fertility, 234 Preterm birth, 86, 106–107, 108, 141, 149 reproductive years, 41 Postmenopause, 41, 236 Primary care provider (PCP), MCO role of, sexual assault/abuse, 322–323 Postpartum blues and depression, 186–187 346 sexual dysfunction, 27–28 Postpartum hemorrhage, 177–178, 184–185 Primary care role of midwife, 342, 343–344 sociodemographics for intrapartum Postpartum period, 185–188 Primary headaches, 307 prognosis, 163 Postpartum thyroiditis, 298 Primary infection, HSV, 217 stress, 318 Postterm infant, 86, 149 Primigravida, defined, 86 PTSD (posttraumatic stress disorder), 319, Posttraumatic stress disorder (PTSD), 319, Primipara, defined, 86 323 323 Pritchard procedure, 68 Puberty, 38–39 Potassium-sparing agents, 248t Privacy rule, HIPAA, 350–351 Pubic arch, 87 Potentiate drug interaction, 31 Privileging, defined, 344 PUBS (percutaneous umbilical blood Power principle in labor, 168 Professional liability insurance, 342 sampling), 96 PPD (purified protein derivative) test for Professional organizations, 342, 345 PUD (peptic ulcer disease), 276–277 TB, 114 Progesterone, 39, 44, 49 Pulmonary embolus (PE), 250, 252 Index 371

Pulmonary hypoplasia, 153 Respiratory system Selye’s Theory of Stress Response and Purified protein derivative (PPD) test for and aging, 29 Adaptation, 318 TB, 114 disorders of, 256t, 258–259t, 262–269 Senescence, 29 Push/expulsive phase of labor, 168, 173 newborn, 135, 148, 153 Sensory capabilities, newborn, 145–146 Pyelonephritis, 111, 222, 223 physical exam, 15 Sepsis risk for newborn, 141, 150 Pyloric stenosis, 153 pregnancy changes, 84 Sequence abnormalities, fetal, 102 Restitution movement of labor, 174 SERM (selective estrogen reuptake Q Resuscitation of newborn, 138 modulators), 305 QCT (quantitative computed tomography), Retained placenta, 184 Serum hormonal levels, testing for, 49 304 Retinoic acid derivatives, 314 Severe persistent asthma, 266, 267 Qualitative amniotic fluid volume (AFV), 96 Review of systems, 13 Sex-linked genetic abnormalities, 102 Quantitative computed tomography (QCT), Rh isoimmunization, 21, 88, 116–117, 152 Sexual assault/abuse, 322–323 304 Rheumatoid arthritis, 291–293 Sexuality, 12, 27–28, 42–43, 93 Quantitative ultrasound (QUS), 304 Rhymes as memory aid, 3 Sexually transmitted diseases/infections QUS (quantitative ultrasound), 304 “Rhythm” fertility methods, 65–66 (STDs/STIs) RICE therapeutic strategy for strains and chancroid, 49, 220 R sprains, 307 chlamydia, 24, 48, 104, 151, 213–214, Race and ethnicity status, intrapartum Right occiput posterior (ROP) position, 172 220–221 considerations, 163 Rights, patient, 350–351 condoms as prevention method, 61, 62 Radiation therapy during pregnancy, 118, Ring chromosome, 102 gonorrhea, 48, 104, 150, 215–216, 263 119 Risk factor identification, 12, 13, 22–28 HBV (See Hepatitis B virus (HBV)) Radioactive iodine therapy, 299 Ritgen maneuver, 176 HIV (See HIV (human immunodeficiency Rape, defined, 322 Rome criteria for IBS, 273 virus)) Rapid test for HIV, 111 ROP (right occiput posterior) position, 172 HPV, 26, 49, 104, 207, 210, 214 RBCs (red blood cells), 19, 136 Round ligament pain during pregnancy, 90 HSV (See Herpes simplex virus (HSV)) RDS (respiratory distress syndrome), fetal, Rovsing’s sign, 275 LGV, 220–221 96 Rubella, 21, 26, 93, 113, 151 Molluscom contagiosum, 218 Reactivity periods in newborn, 139 in newborns, 140, 150, 151 Real-time vs transvaginal ultrasound, 93 S PID, 60, 221–222 Recall techniques, 2–3 SAB (spontaneous abortion), 60, 99–101 during pregnancy, 103–105 Rectal examination, 25, 43 Sacrosciatic notch, 87 risk assessment, 12 Rectocele, 229 Sacrum, 87 screening tests for, 48–49 Recurrent HSV syndrome, 217 Safety education, 27, 141 syphilis, 48, 103, 141, 150, 218–220 Red blood cells (RBCs), 19, 136 Saline laxatives, 271 trichomoniasis, 49, 105, 212, 235 REEDA symptoms for perineum Sanovsky’s Protocol, 94–95 venereal warts, 49, 104, 214–215 postpartum analysis, 187 SBP (systolic blood pressure), 245 SGA (small for gestational age), 105–106, Referral, defined, 345 S–b-thalassemia disease, 118 178 Refusal of treatment, right of patient to, 350 SC disease (sickle cell–hemoglobin C Shake test for fetal lung maturity, 96 Regional anesthesia, 174 disease), 118 Shingles (herpes zoster), 26, 113–114 Regulation of behavior, newborn SCC (squamous cell carcinoma), 235, 236, Shoulder dystocia, 181–182 capabilities, 146 316 Shoulder presentation, 108 Regulation of nursing practice, 346. See also SCHIP (State Children’s Health Insurance Sickle cell anemia (SS disease) Legal and ethical issues Program), 349 diagnosis, 284, 285 Regurgitation, newborn’s tendency toward, Schultz mechanism for placental delivery, and DMPA contraceptive, 56 137, 148 177 etiology/incidence, 283 Reimbursement issues, 345, 347, 348–349 Seasonal vs perennial allergies, 255 management/treatment, 286 Renal system Second period of reactivity, newborn’s, 139 during pregnancy, 118 BUN function test, 20 Second stage of labor (pushing), 168, screening for, 22 newborn in transition, 137 173–174 Sickle cell–b-thalassemia disease, 118 postpartum changes, 185–186 Second trimester Sickle cell–hemoglobin C disease pregnancy changes, 83–84 bleeding in, 100–101 (SC disease), 118 pyelonephritis, 111, 222, 223 psychosocial changes, 85 Side-effects, 30–31. See also specific Reproductive system, anatomy and Secondary headaches, 307, 309 disorders/problems physiology of, 17–18, 29, 37–38. Secretory phase of uterine cycle, 40 SIDS (sudden infant death syndrome), See also Gynecological disorders; Sedatives for labor pain management, 169 155 Gynecology (normal) Seizures, 56, 310t, 311–313 Sight, physical exam, 14, 29 Reproductive years, 39–41 Selective estrogen reuptake modulators Sigmoidoscopy recommendations, 25, 43 Respect for others as ethical principle, 349 (SERM), 305 SIL (squamous intraepithelial lesion), 235 Respiration of newborn during transition, Selective serotonin and norepinephrine Silastic band and occluded sterilization, 68 135 reuptake inhibitors (SNRIs), 320, 321 Simple partial seizure, 311, 312 Respiratory distress syndrome (RDS), fetal, Selective serotonin reuptake inhibitors Single-energy x-ray absorptiometry (SXA), 96 (SSRIs), 321 304 372 Index

Single-gene (Mendelian) disorders, 102 Sublingual nitroglycerine, 255 Testing and screening. See Diagnostic Sinuses, 15, 29. See also Eye, ear, nose, and Submucosal leiomyomata uteri, 205 studies/lab tests throat Subserosal leiomyomata uteri, 205 Testosterone in hormone therapy, 45 Sinusitis, 261–262 Substance dependency and abuse Test-taking strategies/techniques, 1–9 Skin. See Dermatologic system addictive disorders, 324–325 TET (tubal embryo transfer), 234 SLE (systemic lupus erythematosus), affect on newborn, 97–98, 105, 141, 150, Tetanus and diphtheria, immunization 290–291 152 recommendations, 26, 93 Sleeping patterns in newborn, 145 alcohol, 97–98, 152, 325 Tetralogy of Fallot, 153 Small for gestational age (SGA), 105–106, cannabis, 152, 234 Thelarche, 39 178 and infertility, 234 Thermoregulation of newborn during Small group review test preparation nicotine addiction, 26–27, 97, 99, 101, transition, 135–136 technique, 3 234 Thiazide-type diuretics, 247, 248t Smoking, 26–27, 97, 99, 101, 234 obstetrical complications, 96–98 Thiazolidinediones, 296t SNRIs (selective serotonin and opiates, 97, 152 Thinking skill development for test taking, norepinephrine reuptake inhibitors), prescription drugs, 152 1–3 320, 321 stimulants, 100, 101, 152, 325 Third stage of labor/delivery, 177–178 SOAP format for medical record, 13 Subzonal insertion (SUZI) of sperm by Third trimester Social phobia and anxiety, 319 microinjection, 235 bleeding in, 101 Socioeconomic status, intrapartum Succenturiate lobe placenta, 178 psychosocial changes, 85–86 considerations, 163 Suctioning of infant after delivery, 176–177 Threatened abortion, 99, 100 Solitary autonomous nodule, 298, 299 Sudden infant death syndrome (SIDS), 155 Throat. See Eye, ear, nose, and throat Spermatogenesis, 79 Sulfamethoxazole, 111, 260 Thromboembolic disease, 250–251 Spermicides, 61–64, 69, 187 Sulfonylureas, 296t Thrush in newborn, 148 Spina bifida occulta, 152 Summative drug interaction, 31 Thumb sucking, 146–147 Spinal stenosis, 301 Superficial thrombophlebitis, 250, 251 Thyroid function studies, 21, 25, 43 Sponge, contraceptive, 65 Support people for labor, roles of, 167, 173 Thyroid stimulating hormone (TSH), 21, Spontaneous abortion (SAB), 60, 99–101 Supportive-care-only guidelines, 350 298, 299 Spontaneous vaginal breech delivery, 182 Surgical abortion methods, 70 Thyroiditis, 298, 299 Sprains/strains, 306–307 SUZI (subzonal insertion) of sperm by Thyrotoxicosis (hyperthyroidism), 116, Squamous cell carcinoma (SCC), 235, 236, microinjection, 235 298–300 316 SXA (single-energy x-ray absorptiometry), TIA (transient ischemic attack), 311 Squamous intraepithelial lesion (SIL), 235 304 Tinea, 317–318 SS disease (sickle cell anemia). See Sickle Symmetric growth restriction, 105, 149 Tinidazole, 212 cell anemia (SS disease) Sympatholytics, 247, 248–249t Title XVIII of the Social Security Act (1965), SSRIs (selective serotonin reuptake Sympto-thermal fertility awareness 347 inhibitors), 321 method, 66 TIV (trivalent inactivated influenza Stages of labor, 168–174, 177–178 Synclitism vs asynclitism, 168 vaccine), 93 Standard days fertility awareness method, Syncytiotrophoblast, 80 TM (tympanic membrane), 260 66 Syndrome abnormalities, fetal, 102 Tobacco use, 26–27, 97, 99, 101, 234 Standards of practice, 343 Synergistic drug interaction, 31 Tocolytic drugs, 107, 179 Staphylococcus aureus, 230 Syphilis, 48, 103, 141, 150, 218–220 TOD (target organ damage), 245, 246 State Children’s Health Insurance Program Systemic lupus erythematosus (SLE), Tonic neck response, newborn reflex, 144 (SCHIP), 349 290–291 Tonic-clonic (grand mal) seizure, 311, 312 State jurisdiction over nursing practice Systolic blood pressure (SBP), 245 Topical antibiotics for acne, 314 rules, 343 Topical corticosteroids, 256t, 257, 315 Statins, 253 T Topiramate, 310t Station, initial assessment of fetal position, Tail insurance policy, 342 Tort law, defined, 349 165 Talipes equinovarus, 154 Total breech extraction, 182 Statute of limitations, 350 Target organ damage (TOD), 245, 246 Total cutaneous examination (TCE), 317 STDs/STIs (sexually transmitted diseases/ TB (tuberculosis), 21–22, 25, 114–115, 150, Total palsy in newborns, 151

infections). See Sexually transmitted 267–269 Total thyroxine (T4), 21 diseases/infections (STDs/STIs) TCAs (tricyclic antidepressants), 274, 311 Toxic adenoma, 298, 299 Sterilization methods, 44, 68–69, 92–93 TCE (total cutaneous examination), 317 Toxic multinodular goiter, 298, 299 Stillbirth (fetal death), 86, 103 Tension headaches, 307, 308, 309, 311 Toxic shock syndrome, 63, 230–231 Stimulant abuse, 100, 101, 152, 325 Teratogen issue for fetal development, 93 Toxoplasmosis, 113, 150 Stool for occult blood test, 22, 24 Teratogens, 93 TPAL description for parity, 87, 164 Stool softeners, 270 Terconazole, 232 Tracheoesophageal fistula, 153 Stooling/voiding, newborn care, 140 Terenafine, 318 Tramadol, 306 Strains/sprains, 306–307 Term infant, defined, 86 Transabdominal female sterilization Stress, diagnosis and management, 318 Terparatide, 305 method, 68 Stress vs urge incontinence, 224 Testicular feminization (androgen Transcervical female sterilization Studying process and tips, 4–6, 5t insensitivity), 227–228 procedure, 68 Index 373

Transdermal contraceptive system, 53–54 Urinary incontinence, 223–224 Veracity as ethical principle, 349 Transient ischemic attack (TIA), 311 Urinary tract Vertex presentation, 174–175 Transitional period for newborn, 135–137, disorders of, 110–111, 222–224 Vestibule, 37 139, 178 menopausal changes in, 42 Vestibulitis, 233 Transposition of the greater vessels, 153 USG for gestational age determination, 82 Vibro-acoustic stimulation (VAS), 95 Transvaginal vs real-time ultrasound, 93 Uterine cycle, 40 Violence against women (VAW), 98–99, Transverse lie presentation, 108 Uterine prolapse, 229 321–323 Traumatic injury, secondary headache due Uterus Viral and protozoan infections in newborn, to, 307, 309 anatomy and physiology of, 38, 39 150 Traveler’s diarrhea, 272 environment for pregnancy, 80–81 Viral conjunctivitis, 257, 258 Treponema pallidum, 48, 103, 141, 150, membranes during pregnancy, 80, 107, Viral hepatitis. See Hepatitis entries 218–220 165, 167, 179 Virchow’s triad, 250 Trichomoniasis, 49, 105, 212, 235 during menopause, 42 Vision, physical exam, 14, 25, 29, 43 Tricuspid atresia, 153 physiologic adaptations in pregnancy, Visualization memory aid, 3 Tricyclic antidepressants (TCAs), 274, 311 82–83 Vital signs, monitoring during labor, 167

Triglycerides, 251 postpartum changes, 185, 188 Vitamin B12 deficiency anemia, 282, 283, Triple screen test, 88 UTIs (urinary tract infections), 110–111, 284, 285, 286 Triptans, 309 222–223 Vitamin D nutritional requirements, 23 Trisomy 13, 154 Vitamin K for newborn, 140 Trisomy 18, 154 V Voiding/stooling, newborn care, 140 Trisomy 21 (Down syndrome), 102, 154 Vaccines, 93, 114. See also Immunization Vulva, 37, 48 Trivalent inactivated influenza vaccine recommendations Vulvar carcinoma, 210 (TIV), 93 Vacuum aspiration abortion method, 70 Vulvar dermatoses, 231–233 Truncus arteriosus, 153 Vagina Vulvodynia, 233 T-score for bone density, 50 anatomy and physiology of, 38, 39 Vulvovaginal candidiasis (VVC), 105, TSH (thyroid stimulating hormone), 21, examinations during first stage of labor, 212–213, 235 298, 299 169 Tubal and pelvic pathology leading to infections of, 105, 211–213, 235 W infertility, 233 menopausal changes, 41–42 WBCs (white blood cells), 19, 136 Tubal embryo transfer (TET), 234 physiologic adaptations in pregnancy, 83 Weight Tubal ligation, 188 postpartum changes, 185 assessment of newborn, 144 Tuberculosis (TB), 21–22, 25, 114–115, 150, Vaginal carcinoma, 209–210 postpartum loss of, 186 267–269 Vaginal prolapse, 229 pregnancy gain in, 90–91 Tumors/neoplasms, gynecological, 46, Vaginal ring, contraceptive, 54–55 Well child visits in first 6 weeks of life, 119, 205–211, 214. See also Cancers/ Vaginal spermicides, 61 145–146 carcinomas Valproic acid, 310t Western blot test for HIV, 112, 287 Turner’s syndrome, 228 Varenicline, 27 Wet mounts (gyn test), 46 “Turtle sign” in shoulder dystocia, 181 Varicella-zoster virus (VZV), 26, 113–114 Wharton’s jelly, 81 Tympanic membrane (TM), 260 Varicosities during pregnancy, 89 White blood cells (WBCs), 19, 136 VAS (vibro-acoustic stimulation), 95 Withdrawal contraceptive method, 67 U Vascular disorders, secondary headache Withdrawal of treatment, right of patient Ultrasound testing, 47, 88, 93–94, 304 due to, 307, 309 to, 350 Umbilical cord, 80–81, 141, 180 Vasomotor symptoms of menopause (hot Wood’s screw maneuver, 182 Unresponsive sleep, newborn’s initial flashes), 42, 44, 46 period of, 139 VAW (violence against women), 98–99, Z Urethritis, 222, 223 321–323 Zavanelli maneuver, 182 Urethrocele, 229 Velamentous cord insertion in placenta, Zygote, 79 Urge vs stress incontinence, 224 178 Zygote intrafallopian transfer (ZIFT), 234 Urinalysis, 20, 166 Venereal warts, 49, 104, 214–215 Urinary frequency in pregnancy, 90 Venous thrombi, 250