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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

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Genetic Amniocentesis

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http://medicalpicturesinfo.com/wp-content/uploads/2011/08/Amniocentesis-4.jpg

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• 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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