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DOS CME Course 2014 1 DOS CME Course 2011 1 Oxtober 2010 1 Confidential
Obstetrical and a little GYN Update
Ann Roach, MSN, RNC-OB, RNC-MNN, ACNS-BC
Clinical Nurse Specialist Women’s and Children’s Services Fairview Hospital Cleveland Clinic
© Cleveland Clinic 2014
http://www.babyland.my/image/cache/data/uploads/2013/03/hand-knit-baby-socks-sky-blue-bear-3-650x650.jpg
• 1. Identify a maternal risk factor for gestational diabetes
• 2. Define the diagnostic parameters of preeclampsia
Objectives
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Why Most General Practitioners Dislike OB
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Photo retrieved 1/13/14 from http://2.bp.blogspot.com/-LIUzPJO-Wnc/UBpA2acQ9dI/AAAAAAAAAIs/iHroks2bxis/s1600/Pregnant+Woman.jpg
• 10 lunar months
• 280 days
• Trimesters – 12-14 weeks – 14-28 weeks – 28-40 weeks – Up to 12 weeks postpartum
• Photo retrieved 1/13/14 from http://scienceblogs.com/startswithabang/files/2012/11/larger.jpg
Magic Numbers in OB
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Birth Story
Photo from personal files
• 25 yrs old
• First pregnancy
• Unplanned
• Single
• FOB involved
• Exhaustion
Meet Claire
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50 % of pregnancies are unplanned
• Dating of pregnancy • Early US +/- 1 week • Medical/surgical/psych history • IPV • Smoking/recreational/prescribed • Immunizations
– HPV – Tdap – Flu
• Lifestyle-exercise-illicit/prescribed medications • Nutrition • STD’s and HIV
Claire
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Claire
• Intimate Partner Violence
• Tdap
• Flu
• How do you plan to feed your baby?
• How do you receive your information?
• Centering of pregnancy
• Normal nausea and vomiting of pregnancy vs. hyperemesis
Claire
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Photo retrieved 1/13/14 http://www.prevention.com/sites/default/files/imagecache/slideshow_display/stress-woman-vomiting-410x290.jpg
Hyperemesis
• Definition
• Treatment
• Alternative methods
• Who should be screened?
• When are they screened?
• What does it tell us?
• What do we do for the patient?
Screening in Pregnancy
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Available Screening
• Maternal age at time of delivery – 20%
• Maternal age + low serum alpha fetoprotein(MSAFP) – 42%
• Maternal age + MSAFP + HCG – 67%
• MA + MSAFP + HCG + unconjugated estriol (uE3) – 70 %
• MA + MSAFP + HCG + uE3 + inhibin A + US – 87%
• Noninvasive Prenatal Diagnosis
• The latest and the greatest? – Examines fetal DNA in the maternal bloodstream – Trisomies: 13, 18, 21 – Sex chromosome abnormality – Baby sex or blood type
• Benefits? – Avoid other tests? – As early as 10 weeks – 98% of trisomies detected
• Costs?
• Disclosure of non-paternity
Noninvasive Prenatal Screening
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“our recommendation” • Age over 35 at the time of delivery
• Fetal US findings indicating an increased risk for aneuploidy
• History of a previous pregnancy with a trisomy
• Positive screen test for aneuploidy
• Known parental balanced translocation involving 13 or 21
• Not routine
• Not for multiples
• Doesn’t screen for all chromosome
• Does not promise perfection
Transcervical Chorionic Villus Sampling
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Photo retrieved 1/13/14 from http://health.shorehealth.org/graphics/images/en/19165.jpg
Second Trimester Ultrasound
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Photo retrieved 1/13/14 from http://medicalpicturesinfo.com/wp-content/uploads/2011/09/Omphalocele-5.jpg
http://1.bp.blogspot.com/-MTnYg9aJjms/TcmCPzySjmI/AAAAAAAADq4/3hBWtf1q3ks/s1600/IMG_0569.jpg
Genetic Amniocentesis
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http://medicalpicturesinfo.com/wp-content/uploads/2011/08/Amniocentesis-4.jpg
Photo retrieved 1/13/14 from
• November 2013
• 37 - 42.0 weeks
• 37 - 38.6 Early Term
• 39 - 40.6 Full Term
• 41 - 41.6 Late Term
• 42 and beyond Post Term
Defining Term Pregnancy
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Go the Full Forty
• Photo retrieved 1/13/14 from
• http://www.thehomeopathiccoach.com/storage/pregnant%20belly%20white.jpg?__SQUARESPACE_CACHEVERSION=1260771123626
•http://2.bp.blogspot.com/-MJoqqHG4RwI/UWXM7pKGXeI/AAAAAAAAAXI/cmPtjXj91Yo/s1600/Fundal+Height.gif Photo retrieved 1/13/14 from
• Age 37
• G3T2P0A0L2 (G3P2)
• Married
• Pregnancy Risks – GDM – Preeclampsia – Co-morbidities
Meet Marianne
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Advanced Maternal Age
How old is too old to have a baby?
Gestational Diabetes
• Risk factors
• Screening
• Treating
Implications for fetus
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Retrieved1/13/14 http://media.clinicaladvisor.com/images/2012/11/15/ca1112fetus_20wks_318672.jpg
Implications for Delivery
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Retrieved from http://blogs.babble.com/being-pregnant/files/2011/03/16-lb-big-baby.jpg
• Task Force on Hypertension in Pregnancy – Summary of findings, October 2013
• Chronic Hypertension
• Preeclampsia/eclampsia
• Chronic HTN with superimposed preeclampsia
• Gestational HTN
Preeclampsia
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Eliminated the Dependence upon Protein • In the absence of protein: Diagnosis is HTN in
association with
• Thrombocytopenia
• Impaired liver function ( twice normal)
• New development of renal insufficiency
• Serum creatinine >1.1 mg/dL or doubled in absence of renal disease
• Pulmonary edema
• New onset cerebral or visual disorders
• Severe features S ≥ 160 D ≥ 110
• G2 P1
• Delivered a baby at 33.2 weeks
• Importance of cervical length
• Toolbox – 17 P – Cerclage – Vaginal progesterone
Meet Beth
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Photo retrieved 1/13/14 from http://www.laparoscopyhospital.com/Laparoscopic%20Cervical%20Cerclage2.jpg
Preterm Birth
• 20 0/7- 36 6/7
• Very early 20 0/7-23 6/7
• Early 24 0/7- 31 6/7
• Late 32 0/7- 36 6/7
Preterm Labor
• More than 4 contractions in 20 minutes
• Or more than 8 contractions per hour AND documented cervical change with intact membranes
Preterm Labor
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•http://cdn.blogs.babble.com/being-pregnant/files/2011/05/cervical-effacement.jpg
Primary Prevention
• When was Beth’s last baby? – Short inter-pregnancy interval increases PTL risk
• Lifestyle risks – smoking
• Nutrition – High or low BMI increases PTL risk
Secondary Prevention • STOP Smoking!
• Singleton pregnancy
• 17 alpha hydroxyprogesterone caproate – 250 mg IM starting 16-20 weeks until 36 weeks
• Cervical length measurement- transvaginal ultrasound – 16 weeks, 18-20 weeks, 23 6/7 weeks – Offer cerclage < 15mm – Consider if between 15 and 25 mm – Offer in all women with 3 or more prior preterm births or second
trimester losses regardless of cervical length
• Short Cervix and no other risk factors (<25 mm) – Vaginal progesterone 200 mg daily (single or divided dose)
• UTI’s – Treat – Treat asymptomatic bacteriuria with > 100,000 bacteria per mL
Fetal Fibronectin
• fFN negative and cervical length ≥ 30 mm, the patient has < 2% chance of delivering within 1 week and >95% chance of delivering at 35 weeks without any therapy.
• If positive fFN and/or cervical length <30 mm: administer steroids and tocolysis if having preterm contractions.
• Betamethasone – 12 mg IM every 24 hours for 2 doses
• Dexamethasone – 6 mg IM every 12 hours for 4 doses
• Decreases respiratory distress syndrome in newborns
• Decreases NEC- necrotizing
• Decreases intraventricular hemorrhage
Antenatal Corticosteroids
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• Assistance in getting pregnant
• Multiples
Meet Sarah
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Photos personal library
Postpartum Hemorrhage
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Retrieved from http://www.disease-picture.com/wp-content/uploads/2010/11/24/postpartum-hemorrhage-preventionbq.jpeg
http://www.disease-picture.com/wp-content/uploads/2011/12/21/textbook-of-postpartum-hemorrhagero.jpg
Intrauterine Balloon
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http://a248.e.akamai.net/7/248/432/20101213122053/www.msdlatinamerica.com/ebooks/HysteroscopyVisualPerspectivesofUterineAnatomyPhysiologyandPathology/files/2fcb81c822ce2793849f490b37e8cbf9.gif
Uterine Artery Embolization
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Retrieved from http://www.natural-homeremedies.com/blog/wp-content/uploads/2012/06/Uterine-Artery-Embolization.jpg
Obstetric Drills
• Shoulder dystocias
• Hemorrhage
• Seizures
• Cord prolapse
• House wide
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•http://www.scvmc.org/professionals/residency/obgyn/PublishingImages/OBDrillsPostpartumHem.jpg
Hemorrhage Cart
Cord Blood Banking
Retrieved from http://ecordbloodbanking.com/wp-content/uploads/2011/08/Cord-Blood-Banking-21.jpg
• What are they?
• Anything new?
• What to do?
Inherited Thrombophilias in Pregnancy
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Breastfeeding
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Photo retrieved from http://www.associatedobgyn.net/wp-content/uploads/2012/01/Breast-Feeding-Baby.jpg
• Dr Hale
• Lactmed
Skin to Skin and What about Dads?
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Personal photo bank
• Claire Single
• Marianne preeclamptic GDM
• Beth PTL, PTB, PROM
• Sarah Multiples
What Does The Future Hold For Our Mothers?
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• Pap rules
• Mammogram rules
• Immunization
• Menopause
What About The Rest Of Us?
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Personal photo file
Questions??
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Retrieved from http://vuoriclothing.com/community/wp-content/uploads/2011/03/heart-with-baby-feet.jpg
• Definition of Term Pregnancy. (Nov, 2013). Committee Opinion Number 579. ACOG, Society for Maternal-Fetal Medicine.
• Driggers, R., Seibert, D., (May, 2008). The Journal for Nurse Practitioners. 351-356.
• Guidelines for Perinatal Care 7th Edition. (2012). American Academy of Pediatrics & American College of Obstetricians and Gynecologists.
• Inherited Thrombophilias in Pregnancy. (Sept, 2013). Practice Bulletin Number 138. ACOG.
• Management of Preterm Labor. (June, 2012). Practice Bulletin Number 127. ACOG.
• Opioid Abuse, Dependence, and Addiction in Pregnancy. (May, 2012). Committee Opinion Number 524. ACOG, Committee on Health Care for Underserved Women and the American Society of Addiction Medicine.
• Simpson, K.R., Creehan, P. A., Perinatal Nursing, 4th Ed., AWHONN, Wolters Kluwer, 2013.
• Premature Rupture of Membranes. (Oct. 2013). Practice Bulletin Number 139. ACOG
• The Use of Chromosomal Microarray Analysis in Prenatal Diagnosis. (Dec. 2013). Committee Opinion. ACOG
References
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DOS CME Course 2014 55 DOS CME Course 2011 55